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Hit Print SEPC Family Fun Fest LE Outlets 06-07-2024
DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 L.:[11' [7 I =^c L A K-E LSD N 0RE FAMILY FUN FEST I)MA + EPREME SPECIAL EVENT PERMIT CONDITIONS Name of Event: Family Fun Fest Organizer(s): Hit Print, Inc. Jason Devor (PH: 949-600-0776) Event Address: Outlets at Lake Elsinore Event Date(s): June 7, 8 &9, 2024 Event Time: Friday 4:00 PM to 11:00 PM Saturday 1:00 PM to 11:00 PM Sunday 1:00 PM to 7:00 PM No. Spectators: 750 Setup Date(s)/Time(s): June 3, 2024 starting at 8:00 AM Cleanup Date(s)/Time(s): June 10, 2024 starting at 8:00 AM Event Description: Summer is here, and so is the Family Fun Fest! Join us for an unforgettable weekend filled with vendor booths offering the latest finds, thrilling carnival rides, toe-tapping music, mesmerizing entertainment, and delicious food! It's the perfect way to kick off the summer with endless fun for the entire family! 1. Spectator Parking and Attendants: a. Parking will be designated at the Outlets of Lake Elsinore Parking Lot(s). 2. ADA Compliant: a. Provide ADA Accessible Parking as close as practicable to the tract and admission area. b. Provide ADA Restrooms as near as practicable to the track and concession stands. c. Have personnel ready to assist handicap patrons as needed. 3. Vendors & Exhibitors: DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 a. All vendors selling food shall have the appropriate Riverside County Health Department Permits and submit to the Special Events Coordinator 20 days prior to event. b. All vendors selling products/services are required to maintain a City of Lake Elsinore Business License during the duration of the event (for convenience, the City offers one-day business licenses). c. A minimum of an eight-foot aisle way shall be provided between concessions, waste and sanitation facilities. d. Food vendors shall provide the equivalent of two 30-gallon trash containers within ten (10) feet of their concessions. 4. Generators: a. All liquid fuel generators shall have secondary containment and a spill kit located within 100 feet of the secondary containment. b. Each generator or generator area shall be provided with at least one fire extinguisher with a rating of not less than 2:A-10:B-C. 5. Building and Safety Requirements: a. Permits required for site inspection, stage, and generator. Contact Sonia Salazar for scheduling, ssalazar@lake-elsinore.org. 6. Amplified Sound & Noise Level: a. Amplified sound, live music and performances are permitted during the event. b. The Organizers shall not violate the City's noise ordinance by disturbing the peace. 7. Accessibility of Law Enforcement and Emergency Responders: a. There shall be unobstructed access ways into the event for Law Enforcement and other emergency responders. There shall be clearly marked, unobstructed exits for patrons in the case of an emergency or the need for evacuation arises. b. Emergency access shall have an unobstructed width of not less than 24 feet, except approved security gates in accordance with the California Fire Code, and an unobstructed vertical clearance of not less than 13 feet 6 inches. 8. ABC Licensing/Permits: a. ABC Application to be submitted to the Sheriff's Department no later than 20 days prior to the event. b. Applicant must comply with any and all requirements regulations indicated by the Department of Alcoholic Beverage Control. The issuance of an ABC letter is DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 conditional and is subject to revocation for any violation of the Alcohol Beverage Control Act or other state law. Adequate security measures must be in place to secure all alcoholic beverages from patrons and to prevent accessibility to minors.. ❑ Beer-ID checks on all persons 21 years and older wishing to purchase alcohol AND PUT A WRISTBAND ON EVERY PERSON 21 YEARS OR OLDER. ❑ Limit of one (1) alcohol beverage per person per sale. ❑Alcohol sales to cease one (1) hour prior to end of event 9. Event Staffing: a. Applicant to provide security staffing level equivalent to 1:250 security officers to event attendees. 10. Access/Traffic Control: a. Temporary barricades (sideway vehicles okay) installed at vendor/fair pedestrian entrance/exit points shall be staffed at all times. b. Encroachment Permit($220) is required for any event related activities in the public right of way. ❑A signage plan identifying the proposed location of signs, size and verbiage shall be submitted to Engineering Div. for approval along with the Encroachment Permit Application at least 7 days prior to the event. ❑A Traffic Control plan is not required for this event and placement of traffic control materials/personnel in the public right of way is not permitted. c. Event is responsible for providing safe access to and throughout event for pedestrians. 11. Portable Toilets and Wash Stations: a. Secondary containment (generally trays) required under portable toilets. 12. Trash & Clean-up: a. CR&R shall be used for trash containers for recycled and non-recycled trash/waste and for trash disposal. b. Regular and recyclable trash containers shall be placed throughout the Event. c. Trash shall be kept picked up at all times; trash cans shall be emptied when full and at the close of business. d. All trash cans shall be removed from the site after each event. 13. Stormwater management/pollution prevention: DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 a. Best Management Practices shall be implemented during cleanup; no non-storm water discharges into the Lake or City storm drain system are allowed. b. Organizers are responsible for ensuring that pollutants from the event do not enter the Lake. City Municipal Code 14.08 defines "Pollutant" as: "Pollutant" means anything which causes the deterioration on water quality such that it impairs subsequent and/or competing uses of water. Pollutants may include but are not limited paints, oil and other automotive fluids, soil, rubbish, trash, garbage, debris, refuse, waste, ... hazardous waste, chemicals, ...animal waste, offensive matter of any kind. c. In the event of an illicit discharge, event Organizers are responsible for cleanup. d. The applicant is responsible for event cleanup; all cleanup activities shall be completed within 48 hours after close of the event. 14. Insurance: a. The Organizer(s) shall provide the City with a certificate(s) of insurance in the following amounts: ❑ General Aggregate Per Event: $1,000,000 ❑ Auto Liability: $1,000,000 ❑ Worker's Compensation or waiver $1,000,000 ❑ Alcohol: $5,000,000 b. The Organizer's shall use the following additionally insured statement: City of Lake Elsinore its officers, elected and appointed officials, officers, agents, and employees are named as additional insured per attached ISO form CG20 10 1185. 15. Law Enforcement ❑TBD 16. Fire Department Requirements: a. The Fire Safety requirements of the Lake Elsinore Fire Protection Planning are hereby referenced as a separate attachment in Exhibit and incorporated herein as part of the City's conditions of approval. 17. Security Deposit: a. Organizers shall provide the City with a security deposit in the amount of $1,000 at least twenty (20) days prior to the event date. The Security Deposit shall be held by the City as security for the faithful performance by Organizer(s) of all the obligations stipulated in this conditional agreement. The Security Deposit shall not bear interest. If any event fee shall be overdue and unpaid, or if Organizers DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 shall fail to observe or perform any of its obligations under this License, then City may, at its option and without prejudice to any other remedy which City may have on account thereof appropriate and apply such Security Deposit or so much thereof as may be necessary to compensate City in respect of the payment of the event fees or damage sustained by City due to such breach on the part of Organizers; and Organizers shall forthwith upon demand restore such Security Deposit to the original sum deposited and failure to do so shall be considered a default under this conditional agreement. Should Organizers comply with all of its obligations under this conditional agreement and promptly pay all of the event fees, the balance of the Security Deposit shall be returned in full to Organizers following the end of the event. Summary of Fees: ❑ City Permit Application Processing Fee: $305.06 (waived) ❑ City Refundable Security Deposit Fee: $1,000.00 ❑ City Department Inspection Fee: $TBD ❑ Sheriffs Law Enforcement Fees (Paid to RSO): $TBD The Special Event Permit may be revoked summarily by the City for non-compliance with any of these conditions as set forth above. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 By Signing below, I acknowledge that I've read, understood and agree to these Conditions of Approval. Date: 6/6/2024 1 4:22 PM PDT Name (Print): Jason Devor =edC3 Event Organizer Approved By: Date: 6/6/2024 1 9:32 PM PDT Name (Print): Shannon Buckley DocuSigned by: 5"w RZSF_63SF'Ls12c195_ Assistant City Manager, City of Lake Elsinore Date: 6/6/2024 1 8:40 PM PDT Name (Print): Johnathan O. Skinner DocuSigned by: F.riRFA4.riR:3fi F04 3A Community Services Director, City of Lake Elsinore Date: 6/6/2024 1 9:46 PM PDT Name (Print): Jason Simpson DocuSigned by: ,�aSb1�, Siu�pSb1�, Fss�_Fs3 12 City Manager, City of Lake Elsinore DocuSign Envelope ID:FEE3A82C-F634-4C05-9791-9 llil, 1F742 CITY OF • R PECIAL EVENT APPLICATION . . O . E.ORG ,f / 1 ' c ALL SPECIAL EVENT APPLICATIONS ARE DUE NO LATER THAN SIXTY(60) DAYS PRIOR TO THE EVENT. INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED. WWW.LAKE-ELSI NOR E.ORG/SPECIALEVENTS DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 SUMMARY OF EVENT DESCRIPTION Event Title: Family Fun Fest Description: Summer is here, and so is the Family Fun Fest! Join us for an unforgettable weekend filled with (This should be vendor booths offering the latest finds, thrilling carnival rides, toe-tapping live music, promotional in mesmerizing entertainment, and delicious food. It's the perfect way to kick off the summer with nature and cannot exceed 300 endless fun for the entire family! characters) Admission Fee: Free to enter Event Category: ❑ Run / Walk 0 Circus / Carnival ❑ Parade / March ❑ Festival / Celebration ❑ Concert / Performance ❑ Air Show / Car Show ❑ Farmer's Market 0 Other Shopping Anticipated Attendance: Total 750 Per Day 250 Anticipated Total Per Day Participants: DATE/TIME Set-Up: Date 6/3 - 6/7/2024 Time 8am Event Starts: Date 6/7/2024 Time 2pm Event Ends: Date 6/9/2024 Time 7pm Dismantle: Date 6/10 - 6/13/2024 Time DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 SUMMARY OF EVENT Location Description: Located north of the outlets in the parking lot. 17600 Collier Ave, Lake Elsinore (Information cannot exceed 300 characters) CONTACTS Host Organization: Hit Print Professional Orgainzer: Jason Devor Public Contact (Required) Name: Jason Devor Telephone: ( ) 949-600-0776 E-mail: Jason@ihitprint.com Non-Public Contact Name: Jason Devor (Required for Internal Use Only) Telephone: ( ) 951-609-9171 E-mail: Jason@ihitprint.com Web Address: YES NO ❑ ❑m Is this an annual event? How many years have you been holding this event? 1 ORGANIZATION STATUS/PROCEEDS/REPORTING YES NO X❑ ❑ Is the Host Organization a commercial entity? ❑ ❑i Is the Host Organization a bona fide tax exempt, nonprofit entity? If yes,you must attach a copy of your IRS 501(C) tax exempt letter providing proof of status. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 SITE PLAN 1 ROUTE I MAP Your event site plan/route map should be submitted with this application and include but not limited to: An outline of the entire event venue including the names of all streets or areas that are part of the venue and the surrounding area. If the event involves a moving route of any kind, indicate the direction of travel and all street or lane closures. ❑ The location of fencing,barriers and/or barricades. Indicate any removable fencing for emergency access. ❑ The provision of minimum of twenty-four foot (24') emergency access lanes throughout the event venue. ❑ The location of first aid facilities and ambulances. ❑ The location of all stages, platforms, scaffolding,bleachers, grandstands, canopies, tents, portable toilets, booths,beer gardens, cooking areas, trash containers, dumpsters, and other temporary structures. ❑ A detail or close-up of the food booth and cooking area configuration including booth identification of all vendors cooking with flammable gases or barbecue grills. ❑ Generator locations and/or source of electricity. ❑ Placement of vehicles and/or trailers. ❑ Exit locations for outdoor events that are fenced and/or locations within tents and tent structures. Identification of all event components that meet accessibility standards. Other related event components not listed above. ACCESSIBILITY PLAN This checklist is intended to serve as a planning guideline. You may attach more detailed information. YES NO X❑ ❑ Will there be a clear path of travel throughout your venue? X❑ ❑ Have you developed a Disabled Parking and/or Transportation Plan? X❑ ❑ Will a minimum of 10% of portable restrooms at your event be accessible? X❑ ❑ Will all food,beverage and vending areas be accessible? X❑ ❑ Will all signage be provided in highly contrasting colors and placed so pedestrian flow will not obstruct its visability? X❑ ❑ If an information center is provided at your event will customer service representatives be available to assist disabled individuals? DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 SECURITY PLAN YES NO X❑ ❑ Have you hired a licensed professional security company to develop and manage your event's security plan? If yes,you are required to provide a copy of the security company's valid Private Patrol Operator's License issued by the State of California. Security Organization: One Shield Security Services Street 145 Tiger Run Ct, Ste 107 City, State, CA Carlsbad, CA 92010 Telephone Day (760) 536-9000 Cell (760) 536-9000 Private Patrol Operator License #: Please describe your security plan including crowd control, interal security or venue safety, or attach the plan to this application. Similar to the We Love America Festival, unarmed guards doing bag checks at entry with along with patrol of the entire event. YES NO X❑ ❑ Does your event involve the use of alcoholic beverages? If yes,please check all that apply: ❑ Free/Host Alcohol �■ Alcohol Sales ❑ Host and Sale Alcohol ❑ Beer ❑ Beer and Wine Please describe your security plan to ensure safe sale or distribution of alcohol at your event. Use private security company to monitor consumption and baracaded alcohol areas. ID check with wrist bands. * Please advise, if alcohol is being served, additional insurance will be required. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 MEDICAL PLAN YES NO 0 1-1 Have you hired a licensed professional emergency medical services provider to develop and manage your event's medical plan? If yes, please list: Medical Services Provider AMR Street 879 Marlborough Ave. City, State, CA Riverside, CA 92507 Telephone Day 951.782.5200 Cell Business License #: Please describe your medical plan including your communications plan, the number, certification levels (MD, RN, Paramedic, EMT) and types of resources that will be at your event and the manner in which they will be managed and deployed. Your plan should include hours of setup and dismantle of medical aid areas.You may attach the plan to this application if necessary. AMR will handle the complete medical station. Ambulance on stand by for dispatch if necessary. R DEPARTMENT YES NO X❑ Will electrical generators be required during the event? ❑ �■ Will fireworks, explosives,pyrotechnic or any other open flame device be used at the event? Pyrotechnic Company Street City, State, CA Telephone Day Cell Business License #: ❑ ❑� Will the event have a stage? If yes, Please attach stage details. ❑ ❑m Will the event require tents or canopies with over 400 square feet of material? DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 III CONCESSIONS, OR PREPARATION YES NO X❑ ❑ Does your event include food concessions and/or preparation areas? If yes, please describe how food will be served and/or prepared: Hired food trucks with complete permitting included. YES NO ❑o Do you intend to cook food in the event area? If yes,please specify method: ❑ Gas ❑ Electric ❑ Charcoal ❑� Other (specify) Food trucks YES NO X❑ ❑ Will items be sold at your event? Please submit a complete vendor list with this application. All vendors selling merchandise or food are required to have a valid City of Lake Elsinore Business License. All food vendors are required to show current Health Department Permit. AMPLIFIED NOISE YES NO X❑ ❑ Will your event have amplified sound? X❑ ❑ Will your event have mechanical noise? ❑ ❑m Will your event have live music? If yes, Please provide name of band(s) and type of music. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 PORTABLE RESTROOMS You are required to provide portable restroom facilities at your event, unless you can substantiate the sufficient availability of both ADA accessible and nonaccessible facilities in the immediate area of the event site which will be available to the public during your event. YES NO X❑ ❑ Do you plan to provide portable restrooms at your event? If yes, Total number of portable toilets 8 Number of ADA accessible portable toilets 1 If no, Please explain: Restroom Company Dulce Party Rentals Street City, State, CA Escondido, CA 92025 Telephone Day 760-215-3841 Cell 760-215-3841 SANITATION AND R Number of Trash Cans 15 Number of Dumpsters Number of Recycling Containers 5 Sanitation Company CR&R;Attention: Nicole Moore Street City, State, CA Telephone Day 951-657-7513 Cell Due to franchise agreement, CR&R is the only provider available. IMPACTMITIGATION OF YES NO X❑ ❑ Have you presented your event to the surrounding businesses that your event may impact? If yes,please attach a complete list of these entities. ❑ ❑ Do you have a sample of the notice that you propose to distribute two (2) weeks prior to your event? If yes,please attach. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 INSURANCE REQUIREMENTS Name of Insurance Company RVNA Street City, State, CA Telephone Day 818.980.1413 Cell Contact Name: TBD Policy Number: TBD Before final approval of your Special Event Permit Application is granted, a Certificate of Liability Insurance on a ACORD 25 Form shall be provided, naming the City as additionally insured, for the Host Organization and, as applicable, the Primary Contact, Private Security Service Provider, Medical Service Provider, and other service providers if required by the Risk Management Department. All certificates of insurance must provide coverage for the duration of the event, including setup and tear down dates. The City's Risk Management Department has final authority regarding the insurance coverage for the Special Event and can require insurance coverage from other service providers; place requirements on Event Components and/or modify Event Components in a Special Event due to the unique nature or risk of a particular Event or Event Component; and require participant waivers. Certificates of Insurance Must Reflect: Commercial General Liability with limits of: • $1 million per occurrence • $2 million general aggregate Statutory Limits for Workers Compensation and Employers Liability: • $1 million per accident or disease Liquor Liability: • Required if alcohol will be sold at the event • $5 million, but may vary depending on size and nature of event Auto Liability: • $1 million per accident for bodily injury and property damage. Certificate Holder Must Reflect: City of Lake Elsinore 130 S Main Street Lake Elsinore, CA 92530 DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 SPECIAL RELEASE AND IDEMNIFICATION AGREEMENT As Organizer of the event described herein, it is understood that if a permit is approved,we, Jason Devor agree to indemnify the City of Lake Elsinore and its employees, servants and agents, and hold them harmless from any liability, penalty, expense or loss arising out of any injury to any person or damage to any property resulting from the provision or failure to provide services for this special event permit, of the approval thereof, including without restriction any such liability,penalty, or loss resulting from the active or passive negligence of the City, its employees, servants or agents. -4 3/4/2024 Signature of Event Organizer Date AMERICANS WITH DISABILITIES ACT (ADA) As Organizer of the event described herein, it is understood that if a permit is approved,we, Jason Devor agree to follow federal regulations prohibiting discrimination on the basis of race, color, national orgin, age, or disability. 4-4 3/4/2024 Signature of Event Organizer Date •• • - ••_ '• 1 •L�. Jam_S_ ..�.: _�iy+�� _ ��`.� '+ r'� M Emergency Lane 24' Wide 20'X40' N W (n ( W CANOPY N 0 = 0 = 0 = 0 = 0 = 0 = (no walls) LU X O O z O z O z O z 0 o L wCD 0 w 0 w 0 w 0 w 0 w 0 I— X ~ > CO > CO > CO > m > m > m zo'x 40' V) Y IN CANOPY no walls) N MII]�-- - - t • to � _ � ;��• , !.s . 'figdft- r 4 s Ik FBI k. (. v "+�. . _ r 6ft Barricades Vendor Booths Spider Box Cord Temporary -with Privacy Mesh Fence EWrestling Ring ••• Truck Electrical Hot Water Station 15 $ t °swr it a 1,b mm Ir •. TV ® Won o OF Fc@m as . �MIF Qu a =.ry - j 45 Designated RTA 3 � Parking Spaces G©rller A,, Exit Only _ Must Turn Right CpNlpr Ay� �F��Enter Only��� letgyvs=- COI IherAve .`• ,• f ni�1lr Co�PJCr i5 rt ( 4her Ave rmiam `, -- mm COPIrer Ave - - - .4 -- Collier AMe _ - „�•"` t - - _ - ry COWer Ave } � T-�, Colf�er Atie Ow- Entry/Exit Point DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 Parking Access/ Emergency Lane Goaoracor� � Storage Vans Major Ride �" " - ° Major Ride Line Up Games Line Up Games 0 � 20'FIRE LANE Kids Kids Kids Kids >~ W a 20' FIRE LANE v , bf1 W Y Center Games W � U � Q 20' FIRE LANE bJJ Kids Kids CL `D Major Ride Major Ride Major Ride Major Ride 0 Collier Ave. Lake Elsinore Carnival : 17600 Collier Ave. June 07-09, 2024 Christiansen Amusements Lake Elsinore, CA P. O. Box 997, Escondido, CA 92033-0997 Fri. 5 pm- 11 pm (760) 735-8542(fax) 760-735-8543 Sat. 1pm— llpm info*amusements.com Sun. 1pm— lopm Carnival: (Major Rides 50-60'; Kiddie 32-40'): �= Fire Extinguisher X DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 CAL FIRE - RIVERSIDE UNIT RIVERSIDE COUNTY FIRE DEPARTMENT BILL WEISER-FIRE CHIEF rpm` 2 10 WEST SAN JACINTO AVENUE, PERRIS, CA 92570-1 9 1 5 Bus: (951) 940-6900 FAX: (951) 940-6373 WWW.RVCFIRE.ORG PROUDLY SERVING THE UNINCORPORATED May 29th, 2024 AREAS OF RIVERSIDE Y COUNTY AND THE CITIES OF: Family Fun Festival 6/7/2024-6/9/2024 BANNING The Fire Department has approved your application with the following BEAUMONT conditions. COACHELLA DESERT HOT SPRINGS • A Fire Department permit review and inspection fee is required to be paid prior to issuing your special event permit. EASTVALE INDIAN WELLS . Maintain required fire apparatus access around red curbed areas and INDIO Emergency access. JURUPA VALLEY • Stages must have a portable fire extinguisher with a minimum rating of LAKE ELSINORE 2-A 10-BC. LA QUINTA MENIFEE • Provide portable fire extinguishers with a minimum rating of 2-A 10-BC MORENO VALLEY throughout the Vendor Village. Maximum travel distance from any point within the event to a portable fire extinguisher shall not exceed 75 feet. NORCO Fire extinguishers must be securely mounted. PALM DESERT PERRIS • Temporary power cords shall not be affixed to structures, extended through walls, or subject to environmental or physical damage. Cords RANCHO MIRAGE must be secured to prevent a tripping hazard. Large diameter cords RUBIDOUXCSD must be provided with cord bridges or ramps to facilitate the crossing of SAN JACINTO wheelchairs, strollers, and similar wheeled equipment. TEMECULA • Each generator or generator area shall be provided with at least one fire WILDOMAR extinguisher with a rating of not less than 2-A 10-BC. BOARD OF SUPERVISORS: • Canopies must be arranged in groups that do not exceed 700 square KEVINJEFFRIES feet total. Groups of canopies must be separated by a 12-foot fire break DISTRICT 1 between groups. KAREN SPIEGEL DISTRICT 2 • Carnaval rides must have State of California Approval sticker current at CHARLES WASHINGTON time of inspection. DISTRICT 3 V.MANUEL PEREZ Applicant shall be responsible to contact the Fire Department to schedule DISTRICT inspections. Requests for inspections are to be made at least 72 hours in DR.YXSTIAN GUTIERREZ advance and may be arranged by calling 951-674-3124 ext. 250 DISTRICTS All questions regarding the meaning of these conditions should be referred to the Office of the Fire Marshal staff at 951-674-3124 ext. 225 Chris Adams Fire Safety Specialist DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D25lF742 Y e odvr,�_F �QNMENTAL H� County of Riverside DEPARTMENT OF ENVIRONMENTAL HEALTH www.rivcoeh.org 05- �D sr���-``:� rfi Irl. 11 Ay,� 0%j, tiELL EEO yr Department of Environmental Health Non-Profit# P.O.Box 7909 ;:�, .` 0 Riverside,CA 92513-7909 iki .- .; OCR# Tier 1/Tie;, 11'1 �z 30 APPLICATION TO OPERATE A TEMPORARY FOOD FACILITY Riverside County Code 4.52 and the California Health and Safety Code THIS APPLICATION IS FOR: Q TEMPORARY EVENT (4-25 DAYS IN A 90 DAY PERIOD) Q OCCASIONAL EVENT (3 DAYS OR LESS IN A 90 DAY PERIOD) NAME OF OWNER:Jason Devor FACILITYNAME: Family Fun Fest BILLING ADDRESS: 28497 HWY74 #1 13 CITY: Lake Elsinore STATE: CA ZIP: 925j( BUSINESS TELEPHONE: 951-906-9171 HOME TELEPHONE: 951-906-9171 EMAIL ADDRESS: Jason@ihitprint.Com NAME AND LOCATION OF EVENT: Outlets at Lake Elsinore, 17600 Collier Ave, Lake Elsinore, CA 92530 DATE(S)OF EVENT:6/7, 6/8, 6/9 NUMBER OF DAYS: 3 NUMBER OF PARTICIPANTS EXPECTED:2500 DATE SITE PLAN SUBMITTED:5/2312024 SITE PLAN APPROVED BY: *SUBMIT THIS APPLICATION AT LEAST TEN(10)DAYS PRIOR TO THE EVENT. COMMUNITY EVENTS: TEMPORARY EVENTS OCCASIONAL EVENTS E] OPERATIONAL PERMIT(PER BOOTH) $210.00 $102.00 100%PREPACKAGED BOOTH $114.00 $64.00 0 STATIONARY MOBILE FOOD PREPARATION UNIT $148,00 $81.00 COMMUNITY EVENT DISCOUNTED PERMIT FEES: M 1-5 VENDORS $678.00 $207.00 Q/ 6-10 VENDORS $1,271.00 $332.00 I` 11-15 VENDORS $1,865.00 $453.00 16-20 VENDORS $2,458.00 $575.00 rj 21-25 VENDORS $3 050,00 $698.00 26-30 VENDORS $3,644.00 $822.00 0 31-35 VENDORS $4,236.00 $944.00 0 3640 VENDORS $4,830.00 $1,067.00 4145 VENDORS $5,424.00 $1,190.00 0 46-50 VENDORS $6,016.00 $1,311.00 0 51-55 VENDORS $6,609.00 $1,435.00 ❑ 56-60 VENDORS $7,202.00 $1,558.00 0 61-65 VENDORS $7,795.00 $1,681.00 ❑ 66-70 VENDORS $8,390.00 $1,803.00 0 71-75 VENDORS $8,981.00 $1,925.00 0 76-80 VENDORS $9,573.00 $2,048.00 0 81-85 VENDORS $10,167.00 $2,172.00 0 86-90 VENDORS $10,760,00 $2,294.00 91-95 VENDORS $11,354.00 $2,416.00 0 96+VENDORS S11,946.00 $2,539.00 *EVENT ORGANIZER FEE Event organizers will be required to submit a"Temporary Food Facility Community Event Coordinator's Application"form and all applicable fees at least two(2)weeks prior to the event. If the event organizer does not wish to purchase one of the discounted blanket permits listed above,a separate fee will be required. See current fee schedule for a complete list of organizer fee amounts as they vary depending upon the number of vendors operating at the event. Please submit payment WITH YOUR APPLICATION. Permit fees may be paid with cash,or select major credit card(contact area office for details)or money order payable to R' County Department of Environmental Health. I HEREBY APPLY FOR A RECEIPT/PERMIT,WITH APPR S TTACHED,TO OPERATE AT THE ABOVE COMMUNITY EVENT. DATE: 5/23/2024 OWNER/OPERATOR: D692207106120/2028 S NA DRIVERS LICENSEW EXP,DATE For Our Office Locations Call Us at (888)722-4234 or Visit Our Website at www.rivcoeh.org c��n ncc_�raFu�r�3 Vnlii 7/1/77-F;/:tn/7:t { DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 i For phone credit card transactions: Date 05/31/2024 - Family Fun Fest 1. Name on card Jason Devore 2. Credit card type (Visa,MasterCard,etc.) Visa 3. Credit card number (iast4digits) 2622 j 4. Billing address (street # only) 15230 5. Zip code 92530 6. FA# or AR# 7. Dollar Amount $453.00 8. Contact phone # 951-906-9171 9. E-mail or fax# Jason@ihitprint.com 10. Approval number M BC 11. staff Initials RC ENV HLTH CORONA F 2276 9 MAIN 5T 0E 204 RC ENV HLTN CORONA CORONA. CA. 92882-6303 2275 S MAIN ST STE 204 S78 731 5616 CORONA, CA. 92fl82-6303 981, ssai �r2 Phone Order" Phone Order RIVERSIDE CTYICORONA FACILITY xxxxxxxxx xx2G 2 VI3 Entry Method: Mariu.il DEFT 2275 S. MAINh1STTAL HA #204LTH VISA Entry Method; t'lanual Total: 10.714 Total: 4 -010 05i124 10:1'5133 6/3144 07:1'i;,4 Inv a: 000000001 �ppr Code; 9334aG 05/31/ 024 000001 Inv 4: 000000001 Appr Cade: 05J1`1G Appr4 0>~11ne #8323 7:20AN BELLE0002 flpprvd: Online M Cade: WC WCH Y ' �V}��IS Cade: UKUKM��CH Y CW2 Cade; MTCH.M 774000 $453-00 W Cade: PIRTCH M The above Service Fee charge #05 I 39 15 for the convenience of this aayment method and is a CRD CARD $463- 00 I agree to pay above total amount n ndite transaction Sayable according tv card Issuer agreement !n addition to the amount due. (Merchant agreement if credit vouched acceYuurptance ceeof thiures indicates acceptance of this Service Fee and your payment to the card I es5uer accordinv to their If x.- payment terms. k X------------------------------------ -,.-' ° Merchant Copy --------- THANK YOui Merchant Copy Ii TWIK Ypu! DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D25lF742 State of California Department of Alcoholic Beverage Control ABC-281 10/99 License Type: 34 One Day Beer & Wine License Nontransferable LICENSE NO. 9654918 Receipt No, 2901552 Fee Paid $150.00 APPLICATION: Geographical Code 3307 Pursuant to the authority granted by the organization named below, the undersigned hereby applies for the above designated license(s) for the location also described below. ORGANIZATION: RCLE FOUNDATION INC LOCATION ADDRESS: 17600 COLLIER AVE -LAKE ELSINORE. CA 92530 — — TYPE OF EVENT: CARNIVAL HR/DATES DURING WHICH June 7, 2024 - June 9,2024 ALCOHOL WILL BE SOLD: 1PM - 1013M ESTIMATED ATTENDANCE: 2500 AUTHORIZED REPRESENTATIVE 1 ADDRESS JASON DEVOR PO BOX 521,LAKE ELSINORE,CA 92532 LICENSE: The above-named organization is hereby licensed, pursuant to Section 24045.1 of the Business and Professions Code and Rule 59.5 of the California Code of Regulations, to engage in the temporary sale of alcoholic beverages for consumption at the above-named location for the period authorized below.This license does not include off-sale ("to-go")privileges. This license may be revoked summarily by the Department if, in the opinion of the Department and/or the local law enforcement agency, it is necessary to protect the safety, welfare, health, peace, and morals of the people of the State. Good for 3 day(s). Date Issued June 4, 2024. A �� � T Direct©r pf.�rleah&L Be -ram DocuSign Envelope ID: FEE3A82C-F634-4CO5-9791-9A64D251F742 705/31/2024 E(M WDD/YYYY) ACOR" CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Will Maddux NAME: East Main Street Insurance Services, Inc. acNN Ext: (530)477-6521 allo Will Maddux E-MAIL er.comlth th f ino eevene ADDRESS: info@theeventhelper.com PO Box 1298 INSURER(S)AFFORDING COVERAGE NAIC# Grass Valley CA 95945 INSURER A: Evanston Insurance Company 35378 INSURED INSURER B: Hit Print, Inc INSURER C: c/o Jason Devor INSURER D: 28497 CA-74 INSURER E: Lake Elsinore CA 92530 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR IN SD WVD POLICY NUMBER MWDD/YYYY MWDD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 TED CLAIMS-MADE � OCCUR PREM SES DAMAGEO(othelr than fire) $ 2,000,000 X Host Liquor Liability MED EXP(Any one person) $ 10,000 A Retail Liquor Liability Y Y 3DS5475-M3338328 06/07/2024 06/10/2024 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 12:01 AM 12:01 AM GENERAL AGGREGATE $ 5,000,000 X POLICY❑ PRO- JECT ❑ LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: Deductible $ 1,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident L $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate holder listed below is named as additional insured per attached MEGL 2217 01 19.Attendance:5000, Event Type: Farmer's Market.Waiver of Subrogation applies per attached CG 24 04 12 19. Primary/Non-Contributory wording applies per attached CIS 20 01 04 13. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The Outlets At Lake Elsinore AUTHORIZED REPRESENTATIVE 17600 Collier Ave,a100 �; Lake Elsinore CA 92530 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 COMMERCIAL GENERAL LIABILITY gig POLICY NUMBER: 3DS5475-M3338328 MARKEV EVANSTON INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED — DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name Of Additional Insured Person(s) Or Organ ization(s): The City of Lake Elsinore 130 S Main St. Lake Elsinore, CA 19250 Prime Media Consulting 28924 Old Town Front St. Ste 102 Temecula CA 92590 Temecula Valley community Events 28924 Old Town Front St. Ste 102 Temecula CA 92590 A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule of this endorsement, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by the acts or omissions of any insured listed under Paragraph 1. or 2. of Section II — Who Is An Insured: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. MEGL 2217 0119 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 2 with its permission. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. All other terms and conditions remain unchanged. MEGL 2217 0119 Includes copyrighted material of Insurance Services Office, Inc., Page 2 of 2 with its permission. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 POLICY NUMBER: 3DS5475-M3338328 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the additional insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and CG 20 01 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 POLICY NUMBER: 3DS5475-M3338328 COMMERCIAL GENERAL LIABILITY CG 24 04 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person(s) Or Organization(s): The City of Lake Elsinore 130 S Main St. Lake Elsinore, CA 19250 Prime Media Consulting 28924 Old Town Front St. Ste 102 Temecula CA 92590 Temecula Valley community Events 28924 Old Town Front St. Ste 102 Temecula CA 92590 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 04 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 0400 04 (Ed. 7-98) EXTENSION OF INFORMATION PAGE Schedule of Forms ITEM 3D POLICY NO. WC 123389 00 Form Numbers Applicable States WORKERS COMPENSATION FORMS AND ENDORSEMENTS WC 04 00 01 B 10-14 CA WC INFORMATION PAGE CA WC 04 00 05 07-98 CA EXTENSION OF INFORMATION PAGE CA WC 00 00 00 C 01-15 INSURANCE POLICY CA PN 04 99 01 I 02-22 CA POLICYHOLDER NOTICE CA PN 04 99 02 B 05-02 CA WC INSURANCE RATING LAWS CA PN 04 99 04 12-01 CA POLICYHOLDER NOTICE — CIGA CA WC 00 04 19 01-01 PREMIUM DUE DATE ENDORSEMENT CA WC 00 04 21 F 08-22 CATASTROPHE (OTHER THAN CERT ACTS) ENDT CA WC 00 04 22 C 01-21 TERRORISM RISK PGM REAUTH ACT DISCL ENDT CA WC 04 03 01 D 02-18 CA POLICY AMENDATORY ENDORSEMENT CA WC 04 03 03 C 07-18 CA OFFICERS & DIRECTORS COVG/EXCLUSION CA WC 04 03 10 01-95 CA DUTY TO DEFEND CA WC 04 03 60 B 01-15 CA EMPLOYERS' LIAB COV AMENDATORY ENDT CA WC 04 04 21 01-08 CA OPTIONAL PREMIUM INCREASE ENDORSEMENT CA WC 04 04 22 01-12 CA SHORT—RATE CANCELATION ENDORSEMENT CA WC 04 06 01 B 01-22 CA CANCELATION ENDT CA ©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCI RB's California Workers' Compensation Insurance Forms Manual ©2001. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 00 01 B (Ed. 10-14) INFORMATION PAGE SiriusPoint America Insurance Company Policy No. WC 123389 00 Insurer ID No(s). 28363 Prior Policy No. 1. Named Insured: Hit Print Inc Individual Mailing Address: 28497 CA-74 0 Corporation 113 Lake Elsinore CA 92530 0 Partnership LLC LLP Email Address: JASON@ IHITPRINT.COM Other: FEIN: 862426833 Intra/Interstate Risk ID No. Other workplaces not shown above: See Schedule of Locations 2. The policy period is from 07-01-2023to 07-01-2024 12:01 A.M. standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: CA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1 , 000 , 000 each accident Bodily Injury by Disease $ 1 , 000 , 000 policy limit Bodily Injury by Disease $ 1 , 000 , 000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: AK AZ AR CO DE DC FL GA IL IN IA KS KY LA MD MI MS MO NE NV NH NJ NM NY NC OK PA RI SC TN TX UT VT VA WV WI D. This policy includes these endorsements and schedules: See Schedule of Forms and Endorsements 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rate Per Estimated Code Estimated Annual $100 of Annual No. Classifications Remuneration Remuneration Premium See Extension of Information Page Experience Modification See Extension of Information Page Total Estimated Annual Premium $ 2 ,594 Minimum Premium $ 723 Deposit Premium $ 432 Premium Adjustment Period: Annual Countersigned B Producer Information: E-COMP, A Division of Granite Insurance Brokers Servicing/Issuing Office 1015 15th Street NW, Suite 600, Washington, DC 20005-2605 Date Copyright 2014 by the Workers'Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 2014. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 00 05 (Ed. 7-98) EXTENSION OF INFORMATION PAGE Classifications ITEM 4 POLICY NO. WC 123389 00 Premium Basis Rate Per $100 Estimated Code Estimated Annual of Annual No. Classifications Remuneration Remuneration Premium 0001-01 Hit Print Inc FEIN # 86-2426833 SIC CODE 2754 NAICS CODE 323111 CA UTAN No: 1111 28497 CA-74 Lake Elsinore CA 92530 8019 Printing - Quick Printing - $ 160,000 2.25 $ 3,600.00 All Employees - Including Clerical Office Employees Clerical Telecommuter Employees and Outside Salespersons Copyright 1998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 2001. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 00 05 (Ed. 7-98) EXTENSION OF INFORMATION PAGE Classifications ITEM 4 POLICY NO. WC 123389 00 Premium Basis Rate Per $100 Estimated Code Estimated Annual of Annual No. Classifications Remuneration Remuneration Premium Total Class Premium $ 3,600.00 9036 Territory Modification 1.00 $ 0.00 9812 Increase Limits 1.011 $ 40.00 9848 Empl Minimum Difference $ 80.00 Total Subject Premium $ 3,720.00 Total Modified Premium $ 3,720.00 9887 Schedule Modification .59 $ -1,525.00 Standard Total $ 2,195.00 0900 Expense Constant $ 160.00 Terrorism Risk Ins Act 9740 2002 .04 $ 64.00 Catastrophe (Other Than Certified Acts of 9741 Terrorism) .02 $ 32.00 Total Estimated Premium $ 2,451.00 CA Admin Revolving Fund 0987 Assess 1.025208 $ 62.00 CA Occ Safety & Health 0000 Fund 1.006572 $ 16.00 0988 CA Fraud Assessment 1.004679 $ 11.00 CA Unins Empl Benefits 0000 Assess 1.001372 $ 3.00 CA Subs Inj Benefits 0000 Assess 1.013703 $ 34.00 California Labor Enforcement & Compliance (LECF) 0000 Assessment 1.007011 $ 17.00 Final Total $ 2,594.00 Policy Total Estimated Cost $ 2,594.00 Copyright 1998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 2001. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to PART ONE all terms of this policy, we agree with you as follows: WORKERS COMPENSATION INSURANCE A. How This Insurance Applies GENERAL SECTION This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. A. The Policy Bodily injury includes resulting death. This policy includes at its effective date the 1. Bodily injury by accident must occur during the Information Page and all endorsements and policy period. schedules listed there. It is a contract of insurance 2. Bodily injury by disease must be caused or between you (the employer named in Item 1 of the aggravated by the conditions of your Information Page) and us (the insurer named on employment. The employee's last day of last the Information Page). The only agreements exposure to the conditions causing or relating to this insurance are stated in this policy. aggravating such bodily injury by disease must The terms of this policy may not be changed or occur during the policy period. waived except by endorsement issued by us to be part of this policy. B. We Will Pay B. Who is Insured We will pay promptly when due the benefits required You are insured if you are an employer named in of you by the workers compensation law. Item 1 of the Information Page. If that employer is a C. We Will Defend partnership, and if you are one of its partners, you are insured, but only in your capacity as an We have the right and duty to defend at our expense employer of the partnership's employees. any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to investigate and settle these claims, proceedings or C. Workers Compensation Law suits. Workers Compensation Law means the workers or We have no duty to defend a claim, proceeding or workmen's compensation law and occupational suit that is not covered by this insurance. disease law of each state or territory named in Item 3.A. of the Information Page. It includes any D. We Will Also Pay amendments to that law which are in effect during the policy period. It does not include any federal We will also pay these costs, in addition to other workers or workmen's compensation law, any amounts payable under this insurance, as part of federal occupational disease law or the provisions any claim, proceeding or suit we defend: of any law that provide nonoccupational disability 1. reasonable expenses incurred at our request, benefits. but not loss of earnings; 2. premiums for bonds to release attachments and D. State for appeal bonds in bond amounts up to the State means any state of the United States of amount payable under this insurance; America, and the District of Columbia. 3. litigation costs taxed against you; 4. interest on a judgment as required by law until E. Locations we offer the amount due under this insurance; This policy covers all of your workplaces listed in and Items 1 or 4 of the Information Page; and it covers 5. expenses we incur. all other workplaces in Item 3.A. states unless you have other insurance or are self-insured for such E. Other Insurance workplaces. We will not pay more than our share of benefits and costs covered by this insurance and other 1 of 6 ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) insurance or self-insurance. Subject to any limits of liability that may apply, all shares will be equal until 5. This insurance conforms to the parts of the the loss is paid. If any insurance or self-insurance workers compensation law that apply to: is exhausted, the shares of all remaining insurance a. benefits payable by this insurance; will be equal until the loss is paid. b. special taxes, payments into security or other special funds, and assessments F. Payments You Must Make payable by us under that law. You are responsible for any payments in excess of 6. Terms of this insurance that conflict with the the benefits regularly provided by the workers workers compensation law are changed by this compensation law including those required statement to conform to that law. because: Nothing in these paragraphs relieves you of your 1. of your serious and willful misconduct; duties under this policy. 2. you knowingly employ an employee in violation of law; PART TWO 3. you fail to comply with a health or safety law or EMPLOYERS LIABILITY INSURANCE regulation; or 4. you discharge, coerce or otherwise discriminate A. How This Insurance Applies against any employee in violation of the workers This employers liability insurance applies to bodily compensation law. injury by accident or bodily injury by disease. Bodily If we make any payments in excess of the benefits injury includes resulting death. regularly provided by the workers compensation 1. The bodily injury must arise out of and in the law on your behalf, you will reimburse us promptly. course of the injured employee's employment by you. G. Recovery From Others 2. The employment must be necessary or We have your rights, and the rights of persons incidental to your work in a state or territory entitled to the benefits of this insurance, to recover listed in Item 3.A. of the Information Page. our payments from anyone liable for the injury. You 3. Bodily injury by accident must occur during the will do everything necessary to protect those rights policy period. for us and to help us enforce them. 4. Bodily injury by disease must be caused or H. Statutory Provisions aggravated by the conditions of your employment. The employee's last day of last These statements apply where they are required by exposure to the conditions causing or law. aggravating such bodily injury by disease must 1. As between an injured worker and us, we have occur during the policy period. notice of the injury when you have notice. 5. If you are sued, the original suit and any related 2. Your default or the bankruptcy or insolvency of legal actions for damages for bodily injury by you or your estate will not relieve us of our accident or by disease must be brought in the duties under this insurance after an injury United States of America, its territories or occurs. possessions, or Canada. 3. We are directly and primarily liable to any person entitled to the benefits payable by this B. We Will Pay insurance. Those persons may enforce our We will pay all sums that you legally must pay as duties; so may an agency authorized by law. damages because of bodily injury to your Enforcement may be against us or against you employees, provided the bodily injury is covered by and us. this Employers Liability Insurance. 4. Jurisdiction over you is jurisdiction over us for The damages we will pay, where recovery is purposes of the workers compensation law. We permitted by law, include damages: are bound by decisions against you under that 1. For which you are liable to a third party by law, subject to the provisions of this policy that reason of a claim or suit against you by that third are not in conflict with that law. party to recover the damages claimed against 2 of 6 ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) such third party as a result of injury to your and 901-944), any other federal workers or employee; workmen's compensation law or other federal 2. For care and loss of services; and occupational disease law, or any amendments to 3. For consequential bodily injury to a spouse, child, these laws; parent, brother or sister of the injured employee; 9. Bodily injury to any person in work subject to the provided that these damages are the direct Federal Employers' Liability Act(45 U.S.C. consequence of bodily injury that arises out of Sections 51 et seq.), any other federal laws and in the course of the injured employee's obligating an employer to pay damages to an employment by you; and employee due to bodily injury arising out of or in 4. Because of bodily injury to your employee that the course of employment, or any amendments arises out of and in the course of employment, to those laws; claimed against you in a capacity other than as 10.Bodily injury to a master or member of the crew employer. of any vessel, and does not cover punitive C. Exclusions damages related to your duty or obligation to provide transportation, wages, maintenance, and This insurance does not cover: cure under any applicable maritime law; 1. Liability assumed under a contract. This 11.Fines or penalties imposed for violation of federal exclusion does not apply to a warranty that your work will be done in a workmanlike manner; or state law; and 2. Punitive or exemplary damages because of 12.Damages payable under the Migrant and bodily injury to an employee employed in Seasonal Agricultural Worker Protection Act(29 violation of law; U.S.C. Sections 1801 et seq.) and under any 3. Bodily injury to an employee while employed in other federal law awarding damages for violation violation of law with your actual knowledge or the of those laws or regulations issued thereunder, actual knowledge of any of your executive and any amendments to those laws. officers; 4. Any obligation imposed by a workers D. We Will Defend compensation, occupational disease, We have the right and duty to defend, at our unemployment compensation, or disability expense, any claim, proceeding or suit against you benefits law, or any similar law; for damages payable by this insurance. We have 5. Bodily injury intentionally caused or aggravated the right to investigate and settle these claims, by you; proceedings and suits. 6. Bodily injury occurring outside the United States We have no duty to defend a claim, proceeding or of America, its territories or possessions, and suit that is not covered by this insurance. We have Canada. This exclusion does not apply to bodily no duty to defend or continue defending after we injury to a citizen or resident of the United States have paid our applicable limit of liability under this of America or Canada who is temporarily outside insurance. these countries; 7. Damages arising out of coercion, criticism, E. We Will Also Pay demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, We will also pay these costs, in addition to other discrimination against or termination of any amounts payable under this insurance, as part of employee, or any personnel practices, policies, any claim, proceeding, or suit we defend: acts or omissions; 1. Reasonable expenses incurred at our request, 8. Bodily injury to any person in work subject to the but not loss of earnings; Longshore and Harbor Workers' Compensation 2. Premiums for bonds to release attachments and Act(33 U.S.C. Sections 901 et seq.), the for appeal bonds in bond amounts up to the limit Nonappropriated Fund Instrumentalities Act (5 of our liability under this insurance; U.S.C. Sections 8171 et seq.), the Outer 3. Litigation costs taxed against you; Continental Shelf Lands Act (43 U.S.C. Sections 4. Interest on a judgment as required by law until 1331 et seq.), the Defense Base Act(42 U.S.C. Sections 1651-1654), the Federal Mine Safety we offer the amount due under this insurance; and Health Act(30 U.S.C. Sections 801 et seq. and 5. Expenses we incur. 3 of 6 ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) F. Other Insurance 2. The amount you owe has been determined with We will not pay more than our share of damages our consent or by actual trial and final judgment. and costs covered by this insurance and other This insurance does not give anyone the right to add insurance or self-insurance. Subject to any limits of us as a defendant in an action against you to liability that apply, all shares will be equal until the determine your liability. The bankruptcy or loss is paid. If any insurance or self-insurance is insolvency of you or your estate will not relieve us of exhausted, the shares of all remaining insurance our obligations under this Part. and self-insurance will be equal until the loss is paid. PART THREE G. Limits of Liability OTHER STATES INSURANCE Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.13. of the Information A. How This Insurance Applies Page. They apply as explained below. 1. This other states insurance applies only if one or 1. Bodily Injury by Accident. The limit shown for more states are shown in Item 3.C. of the "bodily injury by accident—each accident" is the Information Page. most we will pay for all damages covered by this 2. If you begin work in any one of those states after insurance because of bodily injury to one or the effective date of this policy and are not more employees in any one accident. insured or are not self-insured for such work, all A disease is not bodily injury by accident unless provisions of the policy will apply as though that it results directly from bodily injury by accident. state were listed in Item 3.A. of the Information 2. Bodily Injury by Disease. The limit shown for Page. "bodily injury by disease—policy limit" is the 3. We will reimburse you for the benefits required most we will pay for all damages covered by this by the workers compensation law of that state if insurance and arising out of bodily injury by we are not permitted to pay the benefits directly disease, regardless of the number of employees to persons entitled to them. who sustain bodily injury by disease. The limit 4. If you have work on the effective date of this shown for"bodily injury by disease—each policy in any state not listed in Item 3.A. of the employee" is the most we will pay for all Information Page, coverage will not be afforded damages because of bodily injury by disease to for that state unless we are notified within thirty any one employee. days. Bodily injury by disease does not include disease that results directly from a bodily injury B. Notice by accident. Tell us at once if you begin work in any state listed in 3. We will not pay any claims for damages after we Item 3.C. of the Information Page. have paid the applicable limit of our liability under this insurance. PART FOUR YOUR DUTIES IF INJURY OCCURS H. Recovery From Others We have your rights to recover our payment from Tell us at once if injury occurs that may be covered anyone liable for an injury covered by this insurance. by this policy. Your other duties are listed here. You will do everything necessary to protect those 1. Provide for immediate medical and other rights for us and to help us enforce them. services required by the workers compensation law. I. Actions Against Us 2. Give us or our agent the names and addresses There will be no right of action against us under this of the injured persons and of witnesses, and insurance unless: other information we may need. 1. You have complied with all the terms of this 3. Promptly give us all notices, demands and legal policy; and 4of6 ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) papers related to the injury, claim, proceeding or suit. 4. Cooperate with us and assist us, as we may D. Premium Payments request, in the investigation, settlement or You will pay all premium when due. You will pay the defense of any claim, proceeding or suit. premium even if part or all of a workers 5. Do nothing after an injury occurs that would compensation law is not valid. interfere with our right to recover from others. 6. Do not voluntarily make payments, assume E. Final Premium obligations or incur expenses, except at your The premium shown on the Information Page, own cost. schedules, and endorsements is an estimate. The final premium will be determined after this policy PART FIVE ends by using the actual, not the estimated, PREMIUM premium basis and the proper classifications and rates that lawfully apply to the business and work A. Our Manuals covered by this policy. If the final premium is more All premium for this policy will be determined by our than the premium you paid to us, you must pay us manuals of rules, rates, rating plans and the balance. If it is less, we will refund the balance to classifications. We may change our manuals and you. The final premium will not be less than the apply the changes to this policy if authorized by law highest minimum premium for the classifications or a governmental agency regulating this insurance. covered by this policy. If this policy is canceled, final premium will be B. Classifications determined in the following way unless our manuals provide otherwise: Item 4 of the Information Page shows the rate and premium basis for certain business or work 1. If we cancel, final premium will be calculated pro classifications. These classifications were assigned rats based on the time this policy was in force.Final premium will not be less than the pro rats based on an estimate of the exposures you would have during the policy period. If your actual share of the minimum premium. exposures are not properly described by those 2. If you cancel, final premium will be more than classifications, we will assign proper classifications, pro rata; it will be based on the time this policy rates and premium basis by endorsement to this was in force, and increased by our short-rate policy. cancelation table and procedure. Final premium will not be less than the minimum premium. C. Remuneration Premium for each work classification is determined F. Records by multiplying a rate times a premium basis. You will keep records of information needed to Remuneration is the most common premium basis. compute premium. You will provide us with copies of This premium basis includes payroll and all other those records when we ask for them. remuneration paid or payable during the policy period for the services of: G. Audit 1. all your officers and employees engaged in work You will let us examine and audit all your records covered by this policy; and that relate to this policy. These records include 2. all other persons engaged in work that could ledgers,journals, registers, vouchers, contracts, tax make us liable under Part One (Workers reports, payroll and disbursement records, and Compensation Insurance) of this policy. If you programs for storing and retrieving data. We may do not have payroll records for these persons, conduct the audits during regular business hours the contract price for their services and materials during the policy period and within three years after may be used as the premium basis. This the policy period ends. Information developed by paragraph 2 will not apply if you give us proof audit will be used to determine final premium. that the employers of these persons lawfully Insurance rate service organizations have the same secured their workers compensation obligations. rights we have under this provision. 5 of 6 ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) If you die and we receive notice within thirty days PART SIX after your death, we will cover your legal CONDITIONS representative as insured. A. Inspection D. Cancelation We have the right, but are not obliged to inspect 1. You may cancel this policy. You must mail or your workplaces at any time. Our inspections are not deliver advance written notice to us stating when safety inspections. They relate only to the the cancelation is to take effect. insurability of the workplaces and the premiums to 2. We may cancel this policy. We must mail or be charged. We may give you reports on the deliver to you not less than ten days advance conditions we find. We may also recommend written notice stating when the cancelation is to changes. While they may help reduce losses, we do take effect. Mailing that notice to you at your not undertake to perform the duty of any person to mailing address shown in Item 1 of the provide for the health or safety of your employees or Information Page will be sufficient to prove the public. We do not warrant that your workplaces notice. are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate 3. The policy period will end on the day and hour service organizations have the same rights we have stated in the cancelation notice. under this provision. 4. Any of these provisions that conflict with a law that controls the cancelation of the insurance in B. Long Term Policy this policy is changed by this statement to If the policy period is longer than one year and comply with the law. sixteen days, all provisions of this policy will apply as though a new policy were issued on each annual E. Sole Representative anniversary that this policy is in force. The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this C. Transfer of Your Rights and Duties policy, receive return premium, and give or receive Your rights or duties under this policy may not be notice of cancelation. transferred without our written consent. 6 of 6 ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 PN 04 99 01 1 (Ed. 02-22) POLICYHOLDER NOTICE YOUR RIGHT TO RATING AND DIVIDEND INFORMATION I. Information Available to You A. Information Available from Us-SIRIUSPOINT AMERICA INSURANCE COMPANY (1) General questions regarding your policy should be directed to: SIRIUSPOINT AMERICA INSURANCE COMPANY 140 BROADWAY, 32ND FLOOR, NEW YORK, NY 10005-1123 855-705-2716 (2) Dividend Calculation. If this is a participating policy(a policy on which a dividend may be paid), upon payment or non-payment of a dividend,we shall provide a written explanation to you that sets forth the basis of the dividend calculation. The explanation will be in clear, understandable language and will express the dividend as a dollar amount and as a percentage of the earned premium for the policy year on which the dividend is calculated. (3) Claims Information. Pursuant to Sections 3761 and 3762 of the California Labor Code, you are entitled to receive information in our claim files that affects your premium. Copies of documents will be supplied at your expense during reasonable business hours. For claims covered under this policy,we will estimate the ultimate cost of unsettled claims for statistical purposes eighteen months after the policy becomes effective and will report those estimates to the Workers' Compensation Insurance Rating Bureau of California (WCIRB)no later than twenty months after the policy becomes effective.The cost of any settled claims will also be reported at that time.At twelve-month intervals thereafter,we will update and report to the WCIRB the estimated cost of any unsettled claims and the actual final cost of any claims settled in the interim. The amounts we report will be used by the WCIRB to compute your experience modification if you are eligible for experience rating. B. Information Available from the Workers'Compensation Insurance Rating Bureau of California (1) The WCIRB is a licensed rating organization and the California Insurance Commissioner's designated statistical agent.As such, the WCIRB is responsible for administering the California Workers'Compensation Uniform Statistical Reporting Plan-1995 (USRP)and the California Workers'Compensation Experience Rating Plan-1995(ERP).WCIRB contact information is: WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612,Attn: Customer Service; 888.229.2472 (phone);415.778.7272 (fax); and customerservice(@wcirb.com (email). The regulations contained in the USRP and ERP are available for public viewing through the WCIRB's website at wcirb.com. (2) Policyholder Information. Pursuant to California Insurance Code (CIC)Section 11752.6, upon written request, you are entitled to information relating to loss experience, claims, classification assignments, and policy contracts as well as rating plans, rating systems, manual rules, or other information impacting your premium that is maintained in the records of the WCIRB. Complaints and Requests for Action requesting policyholder information should be forwarded to:WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612,Attn: Custodian of Records. The Custodian of Records can be reached at 415.777.0777 (phone)and 415.778.7272 (fax). (3) Experience Rating Form. Each experience rated risk may receive a single copy of its current Experience Rating Form/Worksheet free of charge by completing a Policyholder Experience Rating Worksheet Request Form on the WCIRB's website at wcirb.com/ratesheet.The Experience Rating Form/Worksheet will include a Loss-Free Rating,which is the experience modification that would have been calculated if$0 (zero)actual losses were incurred during the experience period. This hypothetical rating calculation is provided for informational purposes only. II. Dispute Process You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1. A. Our Dispute Resolution Process. [Optional language for insurers that have adopted the WCIRB's Advisory Basic Underwriting Manual: If you are aggrieved by our decision adopting a change in a classification assignment that results in increased premium, or by the application of our rating system to your workers'compensation insurance, you may dispute these matters with us. If you are dissatisfied with the outcome of the initial dispute with us,you may send us a written Complaint and Request for Action as outlined below.] You may send us a written Complaint and Request for Action requesting that we reconsider a change in a classification assignment that results in an increased premium and/or requesting that we review the manner in which our rating system has been applied in connection with the insurance afforded or offered you. Written Complaints and Requests for Action should be forwarded to: SiriusPoint America Insurance Company 140 Broadway,32nd Floor, New York, NY 10005-1123 PN 04 99 01 1 1 of 2 (Ed.02-22) DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 PN 04 99 01 1 (Ed.02-22) After you send your Complaint and Request for Action,we have 30 days to send you a written notice indicating whether your written request will be reviewed. If we agree to review your request, we must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If we decline to review your request, if you are dissatisfied with the decision upon review, or if we fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in paragraph II.C., below. B. Disputing the Actions of the WCIRB. If you have been aggrieved by any decision, action, or omission to act of the WCIRB,you may request, in writing,that the WCIRB reconsider its decision, action, or omission to act.You may also request, in writing,that the WCIRB review the manner in which its rating system has been applied in connection with the insurance afforded or offered you. For requests related to classification disputes, the reporting of experience, or coverage issues, your initial request for review must be received by the WCIRB within 12 months after the expiration date of the policy to which the request for review pertains, except if the request involves the application of the Revision of Losses rule. For requests related to your experience modification, your initial request for review must be received by the WCIRB within 6 months after the issuance, or 12 months after the expiration date, of the experience modification to which the request for review pertains,whichever is later, except if the request for review involves the application of the Revision of Losses rule. If the request involves the Revision of Losses rule,the time to state your appeal may be longer. (See Section VI, Rule 7 of the ERP). You may commence the review process by sending the WCIRB a written Inquiry. Written Inquiries should be sent to:WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612,Attn: Customer Service. Customer Service can be reached at 888.229.2472(phone),415.778.7272(fax)and customerservice(a-wcirb.com (email). If you are dissatisfied with the WCIRB's decision upon an Inquiry, or if the WCIRB fails to respond within 90 days after receipt of the Inquiry,you may pursue the subject of the Inquiry by sending the WCIRB a written Complaint and Request for Action.After you send your Complaint and Request for Action, the WCIRB has 30 days to send you written notice indicating whether your written request will be reviewed. If the WCIRB agrees to review your request, it must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If the WCIRB declines to review your request, if you are dissatisfied with the decision upon review, or if the WCIRB fails to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in paragraph II.C., below.Written Complaints and Requests for Action should be forwarded to:WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612, Attn: Complaints and Reconsideration.The WCIRB's contact information is 888.229.2472 (phone),415.371.5204(fax) and customerservice(&wcirb.com (email). C. California Department of Insurance—Appeals to the Insurance Commissioner.After you follow the appropriate dispute resolution process described above, if(1)we or the WCIRB decline to review your request, (2)you are dissatisfied with the decision upon review, or(3)we or the WCIRB fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner pursuant to CIC Sections 11737, 11752.6, 11753.1 and Title 10, California Code of Regulations, Section 2509.40 et seq.You must file your appeal within 30 days after we or the WCIRB send you the notice rejecting review of your Complaint and Request for Action or the decision upon your Complaint and Request for Action. If no written decision regarding your Complaint and Request for Action is sent,your appeal must be filed within 120 days after you sent your Complaint and Request for Action to us or to the WCIRB.The filing address for all appeals to the Insurance Commissioner is: Administrative Hearing Bureau California Department of Insurance 1901 Harrison Street, 3rd Floor Mailroom Oakland, CA 94612 415.538.4243 You have the right to a hearing before the Insurance Commissioner, and our action, or the action of the WCIRB, may be affirmed, modified or reversed. III. Resources Available to You in Obtaining Information and Pursuing Disputes A. Policyholder Ombudsman. Pursuant to California Insurance Code Section 11752.6, a policyholder ombudsman is available at the WCIRB to assist you in obtaining and evaluating the rating, policy, and claims information referenced in I.A. and I.B., above. The ombudsman may advise you on any dispute with us,the WCIRB, or on an appeal to the Insurance Commissioner pursuant to Section 11737 of the Insurance Code.The address of the policyholder ombudsman is WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612,Attn: Policyholder Ombudsman. The policyholder ombudsman can be reached at 415.778.7159 (phone),415.371.5288 (fax)and ombudsmanC@wcirb.com (email). B. California Department of Insurance—Information and Assistance. Information and assistance on policy questions can be obtained from the Department of Insurance Consumer HOTLINE, 800.927.HELP(4357)or insurance.ca.goy. For questions and correspondence regarding appeals to the Administrative Hearing Bureau, see the contact information in paragraph II.C. This notice does not change the policy to which it is attached. PN 04 99 01 1 2 of 2 (Ed.02-22) DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 PN 04 99 02 B (Ed. 5-02) POLICYHOLDER NOTICE CALIFORNIA WORKERS' COMPENSATION INSURANCE RATING LAWS Pursuant to Section 11752.8 of the California Insurance Code, we are providing you with an explanation of the California workers' compensation rating laws. 1. We establish our own rates for workers' compensation. Our rates, rating plans, and related information are filed with the insurance commissioner and are open for public inspection. 2. The insurance commissioner can disapprove our rates, rating plans, or classifications only if he or she has determined after public hearing that our rates might jeopardize our ability to pay claims or might create a monopoly in the market. A monopoly is defined by law as a market where one insurer writes 20% or more of that part of the California workers' compensation insurance that is not written by the State Compensation Insurance Fund. If the insurance commissioner disapproves our rates, rating plans, or classifications, he or she may order an increase in the rates applicable to outstanding policies. 3. Rating organizations may develop pure premium rates that are subject to the insurance commissioner's approval. A pure premium rate reflects the anticipated cost and expenses of claims per $100 of payroll for a given classification. Pure premium rates are advisory only, as we are not required to use the pure premium rates developed by any rating organization in establishing our own rates. 4. We must adhere to a single, uniform experience rating plan. If you are eligible for experience rating under the plan, we will be required to adjust your premium to reflect your claim history. A better claim history generally results in a lower experience rating modification; more claims, or more expensive claims, generally result in a higher experience rating modification. The uniform experience rating plan, which is developed by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. 5. A standard classification system, developed by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. The standard classification system is a method of recognizing and separating policyholders into industry or occupational groups according to their similarities and/or differences. We can adopt and apply the standard classification system or develop and apply our own classification system, provided we can report the payroll, expenses, and other costs of claims in a way that is consistent with the uniform statistical plan or the standard classification system. 6. Our rates and classifications may not violate the Unruh Civil Rights Act or be unfairly discriminatory. 7. We will provide an appeal process for you to appeal the way we rate your insurance policy. The process requires us to respond to your written appeal within 30 days. If you are not satisfied with the result of your appeal, you may appeal our decision to the insurance commissioner. CALIFORNIA WORKERS' COMPENSATION INSURANCE NOTICE OF NONRENEWAL Section 11664 of the California Insurance Code requires us, in most instances, to provide you with a notice of nonrenewal. Except as specified in paragraphs 1 through 6 below, if we elect to nonrenew your policy, we are required to deliver or mail to you a written notice stating the reason or reasons for the nonrenewal of the policy. The notice is required to be sent to you no earlier than 120 days before the end of the policy period and no later than 30 days before the end of the policy period. If we fail to provide you the required notice, we are required to continue the coverage under the policy with no change in the premium rate until 60 days after we provide you with the required notice. ©2002 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved. Page 1 of 2 DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 PN 04 99 02 B (Ed. 5-02) We are not required to provide you with a notice of nonrenewal in any of the following situations: 1. Your policy was transferred or renewed without a change in its terms or conditions or the rate on which the premium is based to another insurer or other insurers who are members of the same insurance group as us. 2. The policy was extended for 90 days or less and the required notice was given prior to the extension. 3. You obtained replacement coverage or agreed, in writing, within 60 days of the termination of the policy, to obtain that coverage. 4. The policy is for a period of no more than 60 days and you were notified at the time of issuance that it may not be renewed. 5. You requested a change in the terms or conditions or risks covered by the policy within 60 days prior to the end of the policy period. 6. We made a written offer to you to renew the policy at a premium rate increase of less than 25 percent. (A) If the premium rate in your governing classification is to be increased 25 percent or greater and we intend to renew the policy, we shall provide a written notice of a renewal offer not less than 30 days prior to the policy renewal date. The governing classification shall be determined by the rules and regulations established in accordance with California Insurance Code Section 11750.3(c). (B) For purposes of this Notice, "premium rate"means the cost of insurance per unit of exposure prior to the application of individual risk variations based on loss or expense considerations such as scheduled rating and experience rating. This notice does not change the policy to which it is attached. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 07-01-23 Policy No. WC 123389 00 Endorsement No. Insured Hit Print Inc Premium $ Incl . Insurance Company SiriusPoint America Insurance Company Countersigned By ©2002 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved. Page 2 of 2 DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 PN 04 99 04 (Ed. 12-01) POLICYHOLDER NOTICE CALIFORNIA INSURANCE GUARANTEE ASSOCIATION (CIGA) SURCHARGE Companies writing property and casualty insurance business in California are required to participate in the California Insurance Guarantee Association. If a company becomes insolvent, the California Insurance Guarantee Association settles unpaid claims and assesses each insurance company for its fair share. California law requires all companies to surcharge policies to recover those assessments. If your policy is surcharged, "CA Surcharge"or "CA Surcharge (CIGA Surcharge)"with an amount will be displayed on your premium notice. This notice does not change the policy to which it is attached. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 07-01-23 Policy No. WC 123389 00 Endorsement No. Insured Hit Print Inc Premium $ Incl . Insurance Company SiriusPoint America Insurance Company Countersigned By ©2001 by the Workers'Compensation Insurance Bureau of California.All rights reserved. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 19 (Ed. 1-01) PREMIUM DUE DATE ENDORSEMENT This endorsement is used to amend: Section D. of Part Five of the policy is replaced by this provision. PART FIVE PREMIUM D. Premium is amended to read: You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. The due date for audit and retrospective premiums is the date of the billing. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 07-01-23 Policy No. WC 123389 00 Endorsement No. Insured Hit Print Inc Premium $ Incl . Insurance Company SiriusPoint America Insurance Company Countersigned By WC 00 0419 (Ed. 1-01) 9 2000 National Council on Compensation Insurance,Inc. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 21 F (Ed. 08-2022 Countrywide, Ed. 07-2022 in Texas) Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement This endorsement is notification that we are charging premium to cover the losses that may occur in the event of a Catastrophe (Other Than Certified Acts of Terrorism)as that term is defined below. Your policy provides coverage for workers compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism). Coverage for such losses is subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement attached to this policy. For purposes of this endorsement, Catastrophe (Other Than Certified Acts of Terrorism) is defined as: A single event or peril resulting in a group of claims with aggregate workers compensation losses in excess of$50 million. This $50 million threshold applies per occurrence, across all states for which claims arise from a single event or peril. The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism) is shown in Item 4 of the Information Page or in the Schedule below. Schedule State Rate Premium CA . 02 $32 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 0 7—0 1—2 3 Policy No. WC123389 Endorsement No. Insured Hit Print Inc Premium $ Incl . Insurance Company SiriusPoint America Insurance Company Countersigned By Page 1 of 1 WC000421 F (Ed. 08-2022 Countrywide, Ed. 07-2022 in Texas) ©Copyright 2021 National Council on Compensation Insurance,Inc.All Rights Reserved. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 22 C (Ed. 01-2021) Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2019. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto, including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2019. "Act of Terrorism" means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States, as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, property, or infrastructure. c. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss" means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers compensation)that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer Deductible" means, for the period beginning on January 1, 2021, and ending on December 31, 2027, an amount equal to 20% of our direct earned premiums during the immediately preceding calendar year. Page 1 of 2 ©Copyright 2020 National Council on Compensation Insurance,Inc.All Rights Reserved. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WC 00 04 22 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 01-2021) Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a calendar year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds$100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000,we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. Policyholder Disclosure Notice 1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses occurring in any calendar year exceed $200,000,000, the United States Government would pay 80% of our Insured Losses that exceed our Insurer Deductible. 2. Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed $100,000,000,000. 3. The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in Item 4 of the Information Page or in the Schedule below. Schedule State Rate Premium CA . 04 $64 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 0 7—0 1—2 3 Policy No. WC123389 Endorsement No. Insured Hit Print Inc Premium $ Incl . Insurance Company SiriusPoint America Insurance Company Countersigned By Page 2 of 2 WC000422C (Ed. 01-2021) ©Copyright 2020 National Council on Compensation Insurance,Inc.All Rights Reserved. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 01 D (Ed. 2-18) POLICY AMENDATORY ENDORSEMENT—CALIFORNIA It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of California in Item 3 of the Information Page is subject to the following provisions: 1. Minors Illegally Employed—Not Insured.This policy does not cover liability for additional compensation imposed on you under Section 4557, Division IV, Labor Code of the State of California, by reason of injury to an employee under sixteen years of age and illegally employed at the time of injury. 2. Punitive or Exemplary Damages—Uninsurable.This policy does not cover punitive or exemplary damages where insurance of liability therefor is prohibited by law or contrary to public policy. 3. Increase in Indemnity Payment—Reimbursement.You are obligated to reimburse us for the amount of increase in indemnity payments made pursuant to Subdivision (d)of Section 4650 of the California Labor Code, if the late indemnity payment which gives rise to the increase in the amount of payment is due less than seven (7)days after we receive the completed claim form from you. You are obligated to reimburse us for any increase in indemnity payments not covered under this policy and will reimburse us for any increase in indemnity payment not covered under the policy when the aggregate total amount of the reimbursement payments paid in a policy year exceeds one hundred dollars($100). If we notify you in writing,within 30 days of the payment,that you are obligated to reimburse us,we will bill you for the amount of increase in indemnity payment and collect it no later than the final audit.You will have 60 days,following notice of the obligation to reimburse,to appeal the decision of the insurer to the Department of Insurance. 4. Application of Policy. Part One, "Workers Compensation Insurance",A, "How This Insurance Applies", is amended to read as follows: This workers compensation insurance applies to bodily injury by accident or disease, including death resulting therefrom. Bodily injury by accident must occur during the policy period. Bodily injury by disease must be caused or aggravated by the conditions of your employment.Your employee's exposure to those conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. Rate Changes.The premium and rates with respect to the insurance provided by this policy by reason of the designation of California in Item 3 of the Information Page are subject to change if ordered by the Insurance Commissioner of the State of California pursuant to Section 11737 of the California Insurance Code. 6. Long Term Policy. If this policy is written for a period longer than one year, all the provisions of this policy shall apply separately to each consecutive twelve-month period or, if the first or last consecutive period is less than twelve months,to such period of less than twelve months, in the same manner as if a separate policy had been written for each consecutive period. 7. Statutory Provision.Your employee has a first lien upon any amount which becomes owing to you by us on account of this policy, and in the case of your legal incapacity or inability to receive the money and pay it to the claimant,we will pay it directly to the claimant. 8. Part Five, "Premium", E, "Final Premium", is amended to read as follows: The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less,we will refund the balance to you.The final premium will not be less than the highest minimum premium for the classifications covered by this policy. Page 1 of 2 © Copyright 2018 by the Workers'Compensation Insurance Rating Bureau of California.All Rights Reserved. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WC 04 03 01 D WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 2-18) If this policy is canceled,final premium will be determined in the following way unless our manuals provide otherwise: a. If we cancel,final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. b. If you cancel,final premium may be more than pro rata; it will be based on the time this policy was in force, and may be increased by our short-rate cancelation table and procedure. Final premium will not be less than the pro rata share of the minimum premium. It is further agreed that this policy, including all endorsements forming a part thereof, constitutes the entire contract of insurance. No condition, provision, agreement, or understanding not set forth in this policy or such endorsements shall affect such contract or any rights, duties, or privileges arising therefrom. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 0 7-0 1-2 3 Policy No. WC123389 Endorsement No. Insured Hit Print Inc Premium $ Incl . Insurance Company SiriusPoint America Insurance Company Countersigned By Page 2 of 2 WC040301 D (Ed. 2-18) © Copyright 2018 by the Workers'Compensation Insurance Rating Bureau of California.All Rights Reserved. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 03 C (Ed. 7-18) ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE OFFICERS AND DIRECTORS COVERAGE/EXCLUSION—CALIFORNIA If the employer named in Item 1 of the Information Page is a quasi-public or private corporation, this policy applies to all officers and members of boards of directors while rendering actual service for the corporation for pay, as employees, except those excluded below who 1. individually own at least 10 percent of the corporation's issued and outstanding stock, or 2. individually own at least 1 percent of the corporation's issued and outstanding stock if that officer's or member's parent, grandparent, sibling, spouse, or child owns at least 10 percent of the corporation's issued and outstanding stock and that officer or member is covered by a health insurance policy or a health care service plan, or 3. are officers or members of the board of directors of a cooperative corporation organized pursuant to the Cooperative Corporation Law(Corporations Code, Sections 12200- 12704)who state that he or she is covered by both a health care service plan or health insurance policy, and a disability insurance policy that is comparable in scope and coverage, as determined by the Insurance Commissioner,to a workers'compensation policy. If the employer named in Item 1 of the Information Page is a private corporation, or a private cooperative corporation organized pursuant to the Cooperative Corporation Law,this policy applies to an officer or director who is the sole shareholder of the corporation, as an employee, except if excluded below. The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: Officers, Directors and Trustees Excluded Title JASON DEVOR CORPORATE OFFICER Nothing in this endorsement shall be held to vary, alter,waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter,waive or limit the terms, conditions, agreements or limitations in this endorsement. It is further agreed that"remuneration"when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES,AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1,et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 0 7-0 1-2 3 Policy No. WC123389 Endorsement No. Insured Hit Print Inc Premium $ Incl . Insurance Company SiriusPoint America Insurance Company Countersigned By Page 1 of 1 WC040303C (Ed. 7-18) © Copyright 2018 by the Workers'Compensation Insurance Rating Bureau of California.All Rights Reserved. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 10 (Ed. 1-95) DUTY TO DEFEND-CALIFORNIA The insurance afforded by Part One, Section C, "We Will Defend", is hereby deleted and replaced with the following: WE WILL DEFEND We have the right and duty to defend at our expense any claim or proceeding against you before the California Workers' Compensation Appeals Board or its equivalent in any other state (and any appeal of a decision therefrom) for the benefits payable by this workers' compensation insurance. We have the right to investigate and settle these claims or proceedings. We have no duty to defend a claim, proceeding, or suit that is not covered by this insurance. Nothing contained in this Section shall amend, modify, restrict or otherwise alter any obligations or conditions under Part Two-Employer's Liability Insurance of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 07-01-23 Policy No. WC 123389 00 Endorsement No. Insured Hit Print Inc Premium $ Incl . Insurance Company SiriusPoint America Insurance Company Countersigned By WC 04 03 10 (Ed. 1-95) Copyright 1998 by the Workers'Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 1999. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 60 B (Ed. 01-15) EMPLOYERS' LIABILITY COVERAGE AMENDATORY ENDORSEMENT—CALIFORNIA The insurance afforded by Part Two (Employers' Liability Insurance) by reason of designation of California in item 3 of the information page is subject to the following provisions: A. "How This Insurance Applies," is amended to read as follows: A. How This Insurance Applies This employers' liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury means a physical injury, including resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or incidental to your work in California. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. C. The "Exclusions" section is modified as follows (all other exclusions in the "Exclusions" section remain as is): 1. Exclusion 1 is amended to read as follows: 1. liability assumed under a contract. 2. Exclusion 2 is deleted. 3. Exclusion 7 is amended to read as follows: 7. damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, termination of employment, or any personnel practices, policies, acts or omissions. 4. The following exclusions are added: 1. bodily injury to any member of the flying crew of any aircraft. 2. bodily injury to an employee when you are deprived of statutory or common law defenses or are subject to penalty because of your failure to secure your obligations under the workers' compensation law(s)applicable to you or otherwise fail to comply with that law. 3. liability arising from California Labor Code Section 2810.3 which relates to labor contracting. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 0 7-0 1-2 3 Policy No. WC123389 Endorsement No. Insured Hit Print Inc Premium $ Incl . Insurance Company SiriusPoint America Insurance Company Countersigned By ©2015 by the Workers'Compensation Insurance Bureau of California.All Rights Reserved. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 21 (Ed. 1-08) OPTIONAL PREMIUM INCREASE ENDORSEMENT—CALIFORNIA You must provide us, or our authorized representative, access to records necessary to perform a payroll verification audit. If you fail to provide access within 90 days after expiration of the policy, you are liable to pay a total premium equal to 3 times our current estimate of the annual premium for your policy. In addition, if you fail to provide access after our third request within a 90 day or longer period, you are also liable for our costs in attempting to perform the audit unless you provide a compelling business reason for your failure. We will contact you to schedule appointments during normal business hours. We will notify you of your failure to provide access by mailing a certified, return-receipt document stating the increased premium and the total amount of our costs incurred in our attempt(s) to perform an audit. In addition to any other obligations under this contract, 30 days after you receive the notification, you will be obligated to pay the total premium and costs referenced above. If, thereafter, you provide access to your records within three years after the policy expires, or within another mutually agreed upon time, and we succeed in performing the audit to our satisfaction, we will revise your total premium and the costs due to reflect the results of the audit. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 07-01-23 Policy No. WC 123389 00 Endorsement No. Insured Hit Print Inc Premium $ Incl . Insurance Company SiriusPoint America Insurance Company Countersigned By C 2007 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved. DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D25lF742 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 22 (Ed. 01-12) CALIFORNIA SHORT-RATE CANCELLATION ENDORSEMENT It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of California in Item 3 of the Information Page is subject to the following provisions: If you cancel the policy and a disclosure was provided in accordance with Section 481(c) of the California Insurance Code, final premium will be based on the time this policy was in force and increased by the short-rate cancelation table below: Short Rate Cancellation Table Factix tGApl Yytn Fa#rrto AF4*to I Fames M Apf*to Ea-kedVTnrr nnfcr FxTmx1Prffmrn1c EarnedFFeriun Flays ik P'uf cy Shcml RAc Fkmk d Fkaicy in Days ii"qj Shut Pyle Flerind Pricy n flay.•:i 7 Nall ly 91wA Pale far F%wxA Fbkyin PC.(k d Per-tag- Efoct Pond P-ca m Brad FXiucl Pmu stagea UlEd 6 10,9489 47 23 1.7861 92 36 1.4203 1 7 9.5158 48 24 1.8250 93 36 1.4129 4 7 6.3869 49 24 1.7877 94 36 1.3979 5 B 58394 50 24 1.7520 95 37 1.4210 6 a 4 �662 51 24 1.7176 96 37 1.408 7 9 46924 62 25 1.7548 97 37 1,3923 8 9 4.1058 53 25 i.721 ff 98 37 1.3781 9 10 4.05552 54 2.5 1.6899 99 38 1.4010 10 10 3.6496 55 20 t.7255 100 30 1.3970 11 11 3.6496 56 26 1.6947 101 38 1.3733 12 11 3.3455 r,7 26 1.6650 102 38 1.3598 13 12 1. 16139 26 1.6362 103 39 1.3820 14 12 3.1181 5;3 27 t.6704 104 39 1.3688 15 13 3.1 630 60 27 1.6425 105 39 1.3557 16 13 2.0653 61 27 1.6156 106 40 1.37T4 17 14 9 H66 62 27 1,5895 107 40 1.364.6 18 14 - u IC:3 63 2B 1.6222 108 .1.0 1.3519 19 15 2.8818 64 28 1.5969 109 40 1.1395 20 15 2.7377 65 28 1.5723 110 41 1.3605 21 16 2.7012 66 29 1.6030 111 41 1.3482 22 16 2.6547 67 29 1.5799 112 41 1.3362 23 17 2.6980 68 29 1.5666 1 t 3 Al 1.3243 24 17 2.58516 69 29 1.5341 114 42 1.3447 25 1" 2.4621 7i.1 30 1.5643 115 42 1.3330 26 18 2.5270 71 30 1.5423 116 42 1.3215 27 10 2 4334 72 30 1.5200 117 43 1,3414 28 18 23465 73 30 1,5000 1113 43 1.3201 29 18 2.2656 74 31 1.5291 119 43 1.1169 30 19 23117 75 31 1.5067 120 43 1.3079 31 19 22371 76 31 1.4888 121 44 1.3273 32 19 2.1672 7T 32 1.5169 122 44 1.3164 �3 27 2.2121 78 32 1.4974 123 44 1.3057 a4 20 2.1471 79 32 1.4785 124 44 1.2951 35 20 2.0857 80 32 1.4600 125 45 1.3140 36 20 2.0278 81 33 1.4370 126 45 1.3030 37 21 2.0716 82 33 1.4689 12T 45 1.2933 38 21 2.0171 83 33 1.4612 128 46 1.3117 39 21 1.9654 84 34 1.4774 129 46 1.3016 40 21 1.9162 85 34 1.4600 130 46 1.2910 41 22 1.M35 86 34 1.4430 131 a6 1,2817 42 22 19119 87 34 1.4264 1W 47 1.2996 43 22 1.8674 "i 35 1.451 7 133 47 1-2899 44 23 1.9079 L 35 f.4354 134 47 1.2802 45 23 1.8655 !J 35 1.4194 135 47 1.2708 DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 22 (Ed. 01-12) Short Rate Cancellation Table (Cont'd) Famr#nAFW*tn F-af4rtnlly*to I FachrtaAfWFyrrs Earred R wnim frr FarnrA Prtrr&mfrr FamerfPr3mkrn Dayn n Paicy SFrxt RAe Pcnad Pcky n Playa n Potty Burt Fie Period Poky ii Day it Poky Strrt Fie for fraiod Poky i Period P-stager EffOtlt Period Percertag- ff red Period ,P-V-tage effadt 1 1 2882 161 1 2U9 1.1-J05 137 48 12788 182 60 12033 227 TO 1.1255 139 49 1.2696 183 61 1.2167 222 70 1.1206 139 49 1.2867 184 61 1.2101 229 71 1.1317 140 49 1.2775 165 61 1.2035 230 71 1.1267 141 49 1.2684 186 61 1.1970 231 71 1,1219 142 49 1 ' C.r, 18T 61 11906 222 71 1.1170 143 50 1.276 169 62 1.2037 233 72 1,1279 144 50 1.2674 189 62 1.1974 234 _ 1.1231 145 50 1.2596 190 62 1.19110 2M Tt 1.1163 146 50 1.2500 191 62 1.1848 236 72 1,1136 147 51 1.2663 192 63 1.1977 237 72 1.1009 140 51 1,2679 193 63 11914 24 73 1.1195 149 51 1.249_' 194 63 1-1853 239 73 1.1149 150 52 1.2653 195 63 1-1792 240 73 1.1102 151 52 1.2569 196 63 11732 241 73 1.1055 152 52 1.2407 197 64 1.1050 242 74 1.1161 163 52 1.2405 1813 64 1,1790 243 74 1.1115 1554 53 1.2562 199 64 1.1 T39 24 74 1.1070 155 53 1.2481 200 64 1.1680 24b 74 1.1025 156 53 1.2401 201 65 1.1 R04 246 74 1.0960 157 54 12554 772 65 11745 247 T5 1.1003 168 54 1.2476 M 65 1.1587 249 75 1.10 13 159 54 1.239G 204 65 1.1530 249 75 1.0994 160 54 1.23''�, 205 65 1.1573 250 T5 1.0950 101 55 1.24L,, 205 66 1.1694 251 76 1,1052 162 55 1.2392 20T 66 11638 25? 76 1,1003 163 55 1.2316 200 66 11592 251 76 1.0964 164 55 1.2241 209 65 1-15.26 254 75 1.0921 165 56 1.2368 210 67 1.11�45 255 76 1.0878 166 56 1.2313 211 67 1.1590 256 77 1.0919 167 56 1.2240 212 67 11525 267 77 1.006 160 57 1.2304 213 67 1.1401 258 77 110893 169 57 1.2311 214 67 1.1428 259 77 1.0851 170 57 1.22 a8 215 6 B 1.1544 260 77 1.0010 171 57 1.2167 215 60 11401 261 7$ 1.09V 172 58 1.2308 21 T 66 1.1438 262 78 1,085f 172 58 1.2237 219 69 1.1385 263 713 1.CO11' 174 58 1.2167 2t9 69 1.1500 264 7B 1.0784 175 58 1.2097 220 69 1.1448 265 79 1.0061 176 59 1.2236 221 69 1.1396 266 79 1.0840 177 59 1,216T 222 69 11345 267 79 1.0800 178 59 1.2098 223 69 1.1294 20 79 1.0769 179 50 1.2235 224 70 1-1406 269 79 1.11719 180 Be 1 1.2187 1 225 1 70 1 1.1356 1 270 1 60 1 1.0815 DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 22 (Ed. 01-12) Short Rate Cancellation Table (Cont'd) Factorto AppVto Fadbor10 npryyrto FaWrta Appgrtn EarnedR unkrnfar EwriedR uriiurrifQ EamdRraniirn aaysnPabW St mlMe Perked Poky m %nnPoicy S wdRfe PenadPokyn ftnhPoicy Short Raw tbrPeriodPdky kn Period Paaerkiles Wed Period Paoeatages Period Percdtaw Effect 2, 1 1 I 1' 1 t 272 80 1.0735 317 90 1.0363 362 100 1.0003 273 80 1.0696 318 90 1 A330 363 100 1.0065 274 81 1.0790 319 90 1.0290 364 100 1.0027 275 81 1,0751 320 01 1.0380 365 nn 1.0000 276 81 1.0712 321 91 1.0347 277 81 1.0673 322 91 1.0315 279 81 1.0635 323 91 1.0293 279 82 1.0728 324 92 1.0364 260 82 1.0689 325 92 1.0332 281 82 1.0651 325 92 1.0301 202 8� 1,0614 327 92 1,0209 283 83 1.0705 328 92 1.0238 284 83 1,0667 320 03 1,0318 285 83 1.0630 330 93 1-0286 286 83 1-0593 331 93 1.0255 287 83 1.0556 332 93 1.0224 288 84 1.0646 333 94 1.0303 2e9 84 1.0609 334 94 1.0272 290 84 1.0572 335 94 1.0242 291 84 1.0536 336 94 1.0211 292 85 1.0625 337 94 1.0181 293 85 1,0589 338 05 1.0259 294 85 1.0553 339 95 1.0229 295 85 1.0517 340 95 1.0198 298 85 1.0481 341 95 1.0109 297 86 1.0569 342 95 1.0139 298 86 1.0534 343 96 1.0218 299 86 1.0498 344 96 1.0186 300 96 1,0463 345 96 1,0166 301 86 1.0429 .346 96 1.0127 302 87 1.0615 347 97 1.0203 303 87 1.0480 348 97 1.0174 204 87 1.0446 349 97 1-0145 305 87 1.0411 350 97 1-0116 306 88 1-0497 351 97 1-0007 307 88 1.0+462 362 98 1,0102 308 88 1.0429 353 98 1.0133 309 H 1,0395 354 08 1,0105 310 8 , 1.0361 355 98 1.0076 311 89 1,0445 355 99 1.015u 312 89 1.0412 357 99 1.0122 313 89 1.0379 353 99 1 M94 314 89 1.0346 359 99 1.0085 315 90 1.0429 360 99 1.0038 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 0 7-0 1-2 3 Policy No. WC123389 Endorsement No. Insured Hit Print Inc Premium $ Incl . Insurance Company SiriusPoint America Insurance Company Countersigned By DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 01 B (Ed. 01-2022) CALIFORNIA CANCELATION ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. The cancelation condition in Part Six(Conditions)of the policy is replaced by these conditions: Cancelation: 1. You may cancel this policy.You must mail or deliver advance written notice to us stating when the cancelation is to take effect. 2. We may cancel this policy for one or more of the following reasons: a. Non-payment of premium; b. Failure to report payroll; c. Failure to permit us to audit payroll as required by the terms of this policy or of a previous policy issued by us; d. Failure to pay any additional premium resulting from an audit of payroll required by the terms of this policy or any previous policy issued by us; e. Material misrepresentation made by you or your agent; f. Failure to cooperate with us in the investigation of a claim; g. Material failure to comply with federal or state safety orders or written recommendations of our designated loss control representatives; h. The occurrence of a material change in the ownership of your business; i. The occurrence of any change in your business or operations that materially increases the hazard for frequency or severity of loss; j. The occurrence of any change in your business or operation that requires additional or different classification for premium calculation; k. The occurrence of any change in your business or operation which contemplates an activity excluded by our reinsurance treaties. 3. If we cancel your policy for any of the reasons listed in (a)through (f),we will give you 10 days advance written notice, stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. If we cancel your policy for any of the reasons listed in Items (g)through (k),we will give you 30 days advance written notice; however,we agree that in the event of cancelation and reissuance of a policy effective upon a material change in ownership or operations, notice will not be provided. 4. If we mail the notice to you,the stated periods of notice and your right to remedy the condition will be extended by 5 days if the place of mailing and your mailing address is within California, 10 days if the place of mailing or your mailing address is outside of California and 20 days if the place of mailing or your mailing address is outside of the United States. 5. The policy period will end on the day and hour stated in the cancelation notice. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 0 7-0 1-2 3 Policy No. WC123389 Endorsement No. Insured Hit Print Inc Premium $ Incl . Insurance Company SiriusPoint America Insurance Company Countersigned By WC040601 B (Ed. 0 1-22) DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 Commercial Automobile Liability Waiver Form City of Lake Elsinore Contractor(Consultant, etc.): Hit Print, Inc. Automobile Liability Requirements: Minimum Scope of Insurance: Coverage shall be at least as broad as: Insurance Services Office Business Auto Coverage from CA 00 0106 92 covering Automobile Liability, Code 1 (any auto). If the Contractor owns no automobiles, a non-owned auto endorsement to the General Liability policy described above is acceptable. Minimum Limits of Insurance: Contractor shall maintain limits no less than: One million ($1,000,000) per accident for bodily injury and property damage. Waiver Request: Staff confirms that the Vendor is unable to obtain a non-owned auto endorsement to their General Liability Policy. Therefore an Automobile Liability waiver is being requested for the following reason(s): Initial: eLvenclor does not use an automobile in connection with their work. Ds The Vendor's vehicle is not primarily used for commercial purposes.Therefore, although the Vendor has Automobile Liability coverage,the Vendor does not have Commercial Automobile Liability coverage. DocuSigned by: Contractor:! 6/6/2024 1 6:55 PM PDT seaza^� ... Signature Date (DocuSigned by: vA) hv, b_� 6/6/2024 1 9:32 PM PDT Assistant City Manager: r7RFR35A1Fd�4g5 Signature Date DocuSigned by: P aSbin, slwApSbin, 6/6/2024 1 9:46 PM PDT City Manager: Signature Date DocuSign Envelope ID: FEE3A82C-F634-4C05-9791-9A64D251F742 BUSINESS LICENSE CITY OF LAKE ELSINORE This business license is issued for revenue purposes only and does not grant authorization Administrative Services-Licensing to operate a business. This business license is issued without verification that the holder is 130 South Main Street, Lake Elsinore, CA 92530 subject to or exempted from licensing by the state,county,federal government,or any PH(951)674-3124 other governmental agency. Business Name: HIT PRINT, INC. BUSINESS LICENSE NO. 026024 Business Location: 28497 HIGHWAY 74 STE 113 Business Type: SERVICE/GENERAL-MISC. LAKE ELSINORE,CA 92530 Owner Name(s): AMBER DEVOR Description: PRINT AND MARKETING JASON DEVOR Issue Date: 8/1/2023 Expiration Date: 7/31/2024 HIT PRINT, INC. 28497 HIGHWAY 74 STE 113 LAKE ELSINORE, CA 92530 Starting January 1,2021,Assembly Bill 1607 requires the prevention of gender-based discrimination of business establishments.A full notice is available in English or other languages by going to:https://wvfw.dca.ca.gov/publications/ TO BE POSTED IN A CONSPICUOUS PLACE THIS IS YOUR LICENSE • NOT TRANSFERABLE DocuSign Certificate Of Completion Envelope Id: FEE3A82CF6344C0597919A64D251 F742 Status:Completed Subject: Please DocuSign:SEPC Hit Print Family Fun Fest LE Outlets 06-07-2024.pdf Source Envelope: Document Pages:59 Signatures:7 Envelope Originator: Certificate Pages:5 Initials:2 Luz Reyes AutoNav: Enabled 130 S. Main Street Envelopeld Stamping: Enabled Lake Elsinore,CA 92530 Time Zone: (UTC-08:00)Pacific Time(US&Canada) Ireyes@lake-elsinore.org IP Address:47.180.22.242 Record Tracking Status:Original Holder:Luz Reyes Location: DocuSign 6/6/2024 3:04:12 PM Ireyes@lake-elsinore.org Signer Events Signature Timestamp Jason Devor DocuSignedby: Sent:6/6/2024 3:14:26 PM jason@ihitprint.com Resent:6/6/2024 3:17:07 PM President CcFzoo3Fss3 3ac3... Viewed:6/6/2024 4:19:51 PM Security Level: Email,Account Authentication Signed:6/6/2024 4:22:36 PM (None) Signature Adoption: Drawn on Device Using IP Address: 172.56.177.97 Signed using mobile Electronic Record and Signature Disclosure: Accepted:6/6/2024 4:19:51 PM ID:98246cf3-c52d-4911-931a-fb0208fc33d2 __ Jason Devordby Sent:6/6/2024 4:22:39 PM jason@ihitprint.com Resent:6/6/2024 5:38:23 PM President ED—Si,CF2Do3F593734C3 Viewed:6/6/2024 6:30:47 PM Security Level: Email,Account Authentication Signed:6/6/2024 6:55:45 PM (None) Signature Adoption: Drawn on Device Using IP Address: 172.58.36.4 Signed using mobile Electronic Record and Signature Disclosure: Accepted:6/6/2024 6:30:47 PM ID:Oeef0e96-2b92-474b-9567-d3ded3b38dec Johnathan Skinner =RIM by: Sent:6/6/2024 6:55:48 PM jskinner@lake-elsinore.org Viewed:6/6/2024 8:40:15 PM Director of Community Services Signed:6/6/2024 8:40:24 PM Security Level: Email,Account Authentication (None) Signature Adoption: Drawn on Device Using IP Address: 172.115.236.206 Signed using mobile Electronic Record and Signature Disclosure: Accepted:9/4/2019 4:28:28 PM ID:331961fd-3e2e-4bee-8559-8fb50bf28d41 Shannon Buckley ED—Si,ned by: Sent:6/6/2024 8:40:26 PM sbuckley@lake-elsinore.org u.aLu Vu Viewed:6/6/2024 9:31:51 PM Assistant City Manager 678FB35AIE42495 Signed:6/6/2024 9:32:08 PM Security Level: Email,Account Authentication (None) Signature Adoption: Pre-selected Style Using IP Address:47.144.237.78 Signed using mobile Electronic Record and Signature Disclosure: Accepted:6/6/2024 9:31:51 PM ID:2212e918-3c84-4ea9-ad3d-988bf32912cb Signer Events Signature Timestamp Jason Simpson by Sent:6/6/2024 9:32:10 PM jsimpson@lake-elsinore.org EDII"Sig"Id Amv, SiK�PS6VU Viewed:6/6/2024 9:46:38 PM City Manager 1F551F63E6FE412... Signed:6/6/2024 9:46:52 PM city of Lake Elsinore Signature Adoption: Pre-selected Style Security Level: Email,Account Authentication (None) Using IP Address:47.144.249.113 Signed using mobile Electronic Record and Signature Disclosure: Accepted:6/6/2024 9:46:38 PM ID:dal30a5d-9e82-4ddc-ael7-fcbe9bc62d75 In Person Signer Events Signature Timestamp Editor Delivery Events Status Timestamp Agent Delivery Events Status Timestamp Intermediary Delivery Events Status Timestamp Certified Delivery Events Status Timestamp Carbon Copy Events Status Timestamp Beau Davis �*C Sent:6/6/2024 4:22:37 PM bdavis@lake-elsinore.org i L Viewed:6/6/2024 4:24:31 PM Security Level: Email,Account Authentication (None) Electronic Record and Signature Disclosure: Not Offered via DocuSign Beau Davis Sent:6/6/2024 9:46:55 PM bdavis@lake-elsinore.org ED Security Level: Email,Account Authentication (None) Electronic Record and Signature Disclosure: Not Offered via DocuSign Witness Events Signature Timestamp Notary Events Signature Timestamp Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 6/6/2024 3:14:26 PM Envelope Updated Security Checked 6/6/2024 3:17:06 PM Envelope Updated Security Checked 6/6/2024 3:17:06 PM Envelope Updated Security Checked 6/6/2024 5:38:22 PM Envelope Updated Security Checked 6/6/2024 5:38:22 PM Envelope Updated Security Checked 6/6/2024 5:38:22 PM Envelope Updated Security Checked 6/6/2024 5:38:22 PM Envelope Updated Security Checked 6/6/2024 5:38:22 PM Envelope Updated Security Checked 6/6/2024 5:38:22 PM Certified Delivered Security Checked 6/6/2024 9:46:38 PM Signing Complete Security Checked 6/6/2024 9:46:52 PM Completed Security Checked 6/6/2024 9:46:55 PM Payment Events Status Timestamps Electronic Record and Signature Disclosure Electronic Record and Signature Disclosure created on:2/5/2018 9:41:59 AM Parties agreed to:Jason Devor,Jason Devor,Johnathan Skinner,Shannon Buckley,Jason Simpson CONSUMER DISCLOSURE From time to time, Carahsoft OBO City of Lake Elsinore (we,us or Company)may be required by law to provide to you certain written notices or disclosures. 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By checking the `I agree' box, I confirm that: I can access and read this Electronic CONSENT TO ELECTRONIC RECEIPT OF ELECTRONIC CONSUMER DISCLOSURES document; and I can print on paper the disclosure or save or send the disclosure to a place where I can print it, for future reference and access; and • Until or unless I notify Carahsoft OBO City of Lake Elsinore as described above, I consent to receive from exclusively through electronic means all notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to me by Carahsoft OBO City of Lake Elsinore during the course of my relationship with you. DATE IY(MMIDDYYY) A�" CERTIFICATE OF LIABILITY INSURANCE 5/30/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: ESPI Service Team Edgewood Partners Ins. Center PHONE FAx 10877 White Rock Road Ste 300 A/C No Ext: A/C No), Lic#01329370 ADDRESS: ESP I ServiceTeam a icbrokers.com Rancho Cordova CA 95670 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Philadelphia Indemnity Insurance Co 18058 INSURED CDSSERV INSURER B: CDS Services Inc. dba: Legion Pest Management INSURERC: 39520 Murrieta Hot Springs Rd,#219-210 INSURERD: Murrieta CA 92563 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:1853545796 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DDIYYYY MM/DDIYYYY A X COMMERCIAL GENERAL LIABILITY Y Y PHPK2688537000 6/1/2024 6/1/2025 EACH OCCURRENCE $1,000,000 DAMAGE TO RETED CLAIMS-MADE � OCCUR PREMISES(Ea occurrence)) $100,000 X Pesticide/ MED EXP(Any one person) $5,000 X Herbicide PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY❑ PRO- ❑ LOC PRODUCTS-COMP/OP AGG $2,000,000 X JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident L $ A X UMBRELLA LIAB X OCCUR PHUB912363000 6/1/2024 6/1/2025 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$1 n non $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Work performed by Named Insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Lake Elsinore 130 S Main Street AUTHORIZED REPRESENTATIVE Lake Elsinore CA 92530 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PHPK2688537-000 COMMERCIAL GENERAL LIABILITY CG20100413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Locations Of Covered Operations Blanket Additional Insured as required Various locations required by contract by written contract prior to the loss Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage" or "personal and advertising injury" "property damage" occurring after: caused, in whole or in part, by: 1. All work, including materials, parts or 1. Your acts or omissions; or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work" out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of the same project. required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 C. With respect to the insurance afforded to these 2. Available under the applicable Limits of additional insureds, the following is added to Insurance shown in the Declarations; Section III—Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the most we applicable Limits of Insurance shown in the will pay on behalf of the additional insured is the Declarations. amount of insurance: 1. Required by the contract or agreement; or Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13 POLICY NUMBER: PHPK2688537-000 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Blanket Waiver of Transfer of Rights of Recovery as Required by Written Contract Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products- completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 ❑ POLICY NUMBER: PHPK2688537-000 PI-GL-016 (09/15) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II —Who Is An Insured is amended to include as an additional insured any person or organization who is an owner, lessee or contractor, but only with respect to liability for"bodily injury" or "property damage" caused, in whole or in part, by"your work" performed for that additional insured and included in the "products-completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. PI-GL-016 (09/15) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with permission POLICY NUMBER: PHPK2688537-000 PI-PC-006 (03/09) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON-CONTRIBUTORY INSURANCE ENDORSEMENT FOR A SPECIFIED PROJECT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SECTION IV— COMMERCIAL GENERAL LIABILITY CONDITIONS, is amended to include the following additional condition: Primary and Non-Contributory Insurance ADDITIONAL INSURED SCHEDULE Name of Person or Organization: Blanket where required by written contract Specified Project: Any/All Pest Control Services Effective Date:06/01/2024 This insurance is primary to and non-contributory with any other insurance maintained by the person or organization listed above, except for loss resulting from the sole negligence of the named person or organization listed above. This condition applies even if other valid and collectible insurance is available to the Additional Insured for a loss or"occurrence"we cover for this Additional Insured, but only as respects liability arising out of "your work" performed by you for the Additional Insured at the project designated above. This endorsement applies only to: 1. Ongoing operations performed by the Insured on or after the effective date of the endorsement at the project designated above; 2. Liability arising out of or relating to the Insured's negligence; and 3. "Bodily injury" or"property damage" caused by an "occurrence" under COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY that is not otherwise excluded in the policy to which this endorsement applies. 4. "Bodily injury," "property damage," or"environmental damage" caused by an "occurrence" under COVERAGE E PESTICIDE APPLICATOR POLLUTION LIABILITY that is not otherwise excluded in the policy to which this endorsement applies The Additional Insured's limits of insurance do not increase our limits of insurance, as described in SECTION III — LIMITS OF INSURANCE. All other terms, conditions, and exclusions under the policy are applicable to this endorsement and remain unchanged. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 75/9/2024 E(MMIDDYYY) A�" CERTIFICATE OF LIABILITY INSURANCE IY THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Bobby Walpole Arthur J. Gallagher Risk Management Services, LLC PHONE FAx 777 108th Ave NE AIC No Ext: 425-586-1006 A/C No:425-451-3716 #200 ADDRESS: bobby_walpole@ajg.com Bellevue WA 98004 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:T.H.E. Insurance Company 12866 INSURED CHRIAMU-01 INSURERB:AXIS Surplus Insurance Company 26620 Christiansen Amusements, Inc. Southland Shows, Inc. INSURERC: P. O. Box 997 INSURER D: Escondido CA 92033-0997 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:178074074 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DDIYYYY MM/DDIYYYY A X COMMERCIAL GENERAL LIABILITY Y CPP 0100507 14 4/1/2024 4/1/2025 EACH OCCURRENCE $1,000,000 DAMAGE TO TED CLAIMS-MADE1:1 OCCUR PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $10,000,000 POLICY❑ PRO- JECT ❑ LOC PRODUCTS-COMP/OPAGG $1,000,000 X OTHER: $ A AUTOMOBILE LIABILITY CPP 0100507 14 4/1/2024 4/1/2025 COMBINED SINGLE LIMIT $1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ X OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident B X UMBRELLA LIAB X OCCUR P-001-001375964-01 4/1/2024 4/1/2025 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Cert holder is named as additional insured per attached form but only in resepcts to the named insured. RE: Event in Lake Elsinore I event date:June 03-12, 2024 City of Lake Elsinore its officers,elected and appointed officials,officers,agents,and employees,Outlets at Lake Elsinore,Athena Management, Inc.,Hit Print, Inc.,Prime Media Consulting,Temecula Valley Community Events are included as additional insureds with respect to General liability policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Lake Elsinore 130 S Main Street AUTHORIZED REPRESENTATIVE Lake Elsinore CA 92530 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: CPP 0100507 12 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s)Or Organization(s): ANY PERSON OR ORGANIZATION WITH WHOM YOU HAVE AGREED, BECAUSE OF A WRITTEN CONTRACT OR OTHER AGREEMENT THAT REQUIRES YOU TO ADD AS AN ADDITIONAL INSURED AND TO PROVIDE INSURANCE, BUT ONLY WITH RESPECTS TO "BODILY INJURY", "PROPERTY DAMAGE" OR "PERSONAL AND ADVERTISING INJURY" CAUSED IN WHOLE OR IN PART, RESULTING FROM YOUR WORK OR OPERATIONS FOR THE ADDITIONAL INSURED, AS PERMITTED BY LAW. NO COVERAGE APPLIES TO LIABILITY RESULTING FROM THE SOLE NEGLIGENCE OF THE ADDITIONAL INSURED. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III— Limits Of Insurance: with respect to liability for "bodily injury", If coverage provided to the additional insured is "property damage" or "personal and advertising required by a contract or agreement, the most injury" caused, in whole or in part, by your acts we will pay on behalf of the additional insured is or omissions or the acts or omissions of thos a the amount of insurance: acting on your behalf: 1. In the performance of your ongoing 1. Required by the contractor agreement; or operations; or 2. Available under the applicable Limits of Insurance shown in the Declarations; 2. In connection with your premises owned by whichever is less. or rented to you. However : This endorsement shall not increase the 1. The insurance afforded to such additional applicable Limits of Insurance shown in the Declarations. insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 26 04 13 © Insurance Services Office,lnc., 2012 Page 1 of 1 ` 1 " DATE(MMIDDIYYYY) �tccr�r�` CERTIFICATE OF LIABILITY INSURANCE 05/29/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME THIMBLE https://support.thimble.com/ Verify Insurance Services,LLC DBA Thimble Insurance Services PHONE FAx 174 West 4th Street,Suite 204 c No Ext. A/C No), New York,NY 10014 ADOgEss; support@thifrtpie.com https://support.thimble.com/ INSURERS AFFORDING COVERAGE NAIC# _ INSURERA: N?Jignal Specialty Insurance Company 22608 INSURED INSURER B: HERITAGE HAULING LLC 22854 Aqueduct Way,Moreno Valley,CA,92553 INSURER C: Info@hedtagehaul.com INSURER D: INSURER E: INSURERF: https://www.thimble.com/check-policy-status/ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1NSR TYPE OF INSURANCE DL 5t m POLICY NUMBER MMAX)NOLICY YYY LTR DD/MM YYYY LIMITS X COMMERCIAL GENERAL LIABILITY 04/21/2024 04/21/2025 EACH OCCURRENCE S 2,000,000 CLAIMS-MADE � OCCUR 1:52 AM 1:52 AM 61 LN PREMISES Ea occurrence S 10 00 PDT PDT MED EXP(An oneperson) s 5,000 p Y Y IBL-P34T4HA59-1 PERSONAL 8 ADV INJURY S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY El jECT LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: S AUTOMOBILE LIABILITY CCMUINED SINGLE LIMIT s Ea acwfent ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Parecctd..nt S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED I I RETENTIONS S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STAT TE ER ANY PROPRIETOR/PARTNER/EXECUTIVE M N/A E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE s If yes,desmibe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT S S S S S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space isrequired) (con't on form Acord 101) CERTIFICATE HOLDER CANCELLATION City of lake Elsinore 130 s main st SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Lake Elsinore,ca, 92530 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE IyI ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: Info@heritagehaul.com LOC#: 1 ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Verifly Insurance Services, LLC DBA Thimble Insurance Services HERITAGE HAULING LLC 22854 Aqueduct Way,Moreno Valley,CA,92553 POLICY NUMBER Info@heritagehaul.com IBL-P34T4HA59-1 CARRIER NAIC CODE National Specialty Insurance Company 22608 I EFFECTIVE DATE: 04721/2024 1�52 AM PDT ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACDTd 25 FORM TITLE: Certificate of Liability Insurance Description of Operations (con't) Episodic Coverage (THSN CG 02 04 02 21)for policy number IBL-P34T4HA59-1 until 04/21/2026 1:52 AM PDT ACORD 101 (2008/01) @ 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THSN IL 20 20 10 20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM PROFESSIONAL LIABILITY COVERAGE FORM SCHEDULE Name of Designated Person or Organization (including its departments and attached agencies, its directors, officers, officials, employees, representatives and agents): Any person(s)or organization(s)for whom you have agreed in writing in a contract or agreement that such person(s)or organization(s) be added as an additional insured on your policy. E-Mail Address: A. SECTION II — WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the SCHEDULE above, but only with respect to liability for "bodily inju- ry", "property damage", "personal and advertising injury" or "wrongful acts" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insur- ance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to LIM- ITS OF INSURANCE section of the coverage form If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable limits of insurance shown in the Declarations; whichever is less. C. If this policy is cancelled or nonrenewed for any reason, we will deliver notice of the cancellation or non-renewal to any Designated Person or Organization shown in the SCHEDULE above at the e- mail address shown above. D. This endorsement shall not increase the applicable limits of insurance shown in the Declaration All other terms and conditions remain unchanged. THSN IL 20 20 10 20 ©Verifly Insurance Services,Inc.2020 Page 1 of 1 Includes materials copyrighted by Insurance Services Office, Inc., used with its permission POLICY NUMBER: IBL-P34T4HA59-1 COMMERCIAL GENERAL LIABILITY CG24041219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person(s)Or Organization(s): Any person(s) or organization(s)for whom you have agreed in writing in a contract or agreement that such person(s)or organization(s) be added as an additional insured on your policy. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s)shown in the Schedule above. CG 24 04 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 THSN IL 20 20 10 20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM PROFESSIONAL LIABILITY COVERAGE FORM SCHEDULE Name of Designated Person or Organization (including its departments and attached agencies, its directors, officers, officials, employees, representatives and agents): City of lake elsinore E-Mail Address: Bdavis@lake-elsinore.org A. SECTION II — WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the SCHEDULE above, but only with respect to liability for "bodily inju- ry", "property damage", "personal and advertising injury" or "wrongful acts" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. THSN IL 20 20 10 20 ©Verifly Insurance Services,Inc.2020 Page 1 of 2 Includes materials copyrighted by Insurance Services Office, Inc., used with its permission THSN IL 20 20 10 20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insur- ance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to LIM- ITS OF INSURANCE section of the coverage form If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable limits of insurance shown in the Declarations; whichever is less. C. If this policy is cancelled or nonrenewed for any reason, we will deliver notice of the cancellation or non-renewal to any Designated Person or Organization shown in the SCHEDULE above at the e- mail address shown above. D. This endorsement shall not increase the applicable limits of insurance shown in the Declaration All other terms and conditions remain unchanged. THSN IL 20 20 10 20 ©Verifly Insurance Services,Inc.2020 Page 2 of 2 Includes materials copyrighted by Insurance Services Office, Inc., used with its permission COMMERCIAL GENERAL LIABILITY CG 20 01 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the additional insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance;and CG 20 01 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 POLICY NUMBER: IBL-P34T4HA59-1 COMMERCIAL GENERAL LIABILITY CG 24 04 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person(s)Or Organization(s): City of lake elsinore Bdavis@lake-elsinore.org Information required to complete this Schedule, if not shown above,will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 04 12 19 ©Insurance Services Office, Inc., 2018 Page 1 of 1